Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention?
"I want to continue my education, but I'm not sure how I will fit in with other college students."
"It's good to be home. I missed my home, family, and friends."
"Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown."
"I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me."
The Correct Answer is D
A. Concerns about returning to school reflect normal adjustment issues and do not indicate immediate danger.
B. Expressing happiness about being home is a positive statement and does not require urgent intervention.
C. Hypervigilance and startle responses are common symptoms of PTSD and should be monitored but are not immediately life-threatening.
D. Expressions of survivor’s guilt or thoughts questioning why one survived while others did not can indicate severe emotional distress and possible risk for self-harm or suicidal ideation. This statement requires immediate assessment and intervention by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Buspirone – This anxiolytic does not typically cause significant anticholinergic effects.
B. Lithium – Common side effects include tremor, polyuria, and mild gastrointestinal upset, not prominent anticholinergic effects.
C. Imipramine, a tricyclic antidepressant, has strong anticholinergic properties, leading to dry mouth, blurred vision, mydriasis, constipation, and urinary retention.
D. Risperidone – An atypical antipsychotic; anticholinergic effects are minimal compared to tricyclic antidepressants.
Correct Answer is B
Explanation
A. Suicide precautions should never be discontinued at this time; in fact, suicide risk is highest when energy improves before mood fully stabilizes.
B. Increased energy after starting antidepressants raises suicide risk, as the patient may now have the ability to act on suicidal thoughts. Continuous supervision is the priority for safety.
C. Discharge planning is premature at this stage; safety comes first.
D. Art and music therapy may be beneficial long-term but do not address the immediate suicide risk.
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