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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune.
Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications. Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.
Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.
Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.
Correct Answer is ["B","D"]
Explanation
The age-related factors that may factor into this client's wound healing are: Decreased epidermal turnover: As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
T-cell function decrease: The immune system's function, including T-cell function, tends to decline with age. T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
Insulin resistance and pigmentation changes are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes are primarily cosmetic and do not directly affect the physiological processes involved in wound healing.
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