The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

I am at high risk for post-traumatic-stress disorder because I have acute stress disorder

I can use holistic approaches like meditation to help my symptoms.

I can learn to manage my thoughts better through therapy.

Many people have the same response to a stressful situation as I am having.

This diagnosis means that I am crazy.

I will probably need to be on medication for the rest of my life.

I am at high risk for post-traumatic-stress disorder because I have acute stress disorder

I can use holistic approaches like meditation to help my symptoms.

I can learn to manage my thoughts better through therapy.

Many people have the same response to a stressful situation as I am having

This diagnosis means that I am crazy.

I will probably need to be on medication for the rest of my life.

Answer and Explanation

The Correct Answer is ["A","E","F"]

A) Correct- The client's statement suggests a misconception about the progression from acute stress disorder (ASD) to post-traumatic stress disorder (PTSD). While ASD is an initial response to trauma, it doesn't necessarily indicate a high risk for developing PTSD. The nurse should provide education about the differences and the various factors that influence the development of PTSD.

B) Incorrect- This statement reflects the client's proactive approach to using holistic approaches like meditation to manage symptoms. Meditation and other relaxation techniques can be beneficial for managing stress and anxiety related to the traumatic event.

C) Incorrect- This statement reflects the client's motivation to learn how to manage their thoughts better through therapy. Therapy can be highly effective for addressing trauma-related distress and helping clients develop coping strategies.

D) Incorrect- This statement reflects the client's recognition that their response is shared by many people in similar situations. Validating the client's experience and normalizing their feelings can be therapeutic.

E) Correct- This statement reflects a common misconception and stigma associated with mental health diagnoses. The nurse should reassure the client that a diagnosis of acute stress disorder does not equate to being "crazy" and provide information about the nature of the disorder and available treatments.

F) Correct- The statement implies a potential pessimistic outlook on treatment. While medication might be part of the treatment plan, it's important to emphasize that treatment approaches are individualized. Encouraging an open dialogue about various treatment options, including therapy and coping strategies, is essential.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A) Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B) Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Incorrect- Smoking is not a common cause of elevated serum magnesium levels.

D. Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.

A. Pain assessments B. Antibiotics C. Occupational therapy D. Wound care E. Physical therapy

Correct Answer is A

Explanation

Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.

While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.

Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.

These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?