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 B
Explanation
A. Seclusion is a last-resort intervention, not an initial step.
B. Staff meetings to ensure consistent approaches, structure, and limit-setting prevent staff fatigue, reduce defensiveness, and provide therapeutic consistency for the client.
C. Confronting the patient directly about unacceptable behavior may escalate agitation and is not the most effective prevention strategy.
D. Group discussions with patients about one individual’s behavior would be inappropriate and non-therapeutic.
Correct Answer is C
Explanation
A. Patients do not need to double fluid intake, just maintain adequate hydration (2–3 L/day). Drinking twice the usual amount could lead to fluid overload or dilute sodium balance.
B. Lithium should never be doubled. In fact, vomiting and diarrhea increase risk of lithium toxicity, so the provider must be notified instead.
C. Lithium excretion is closely tied to sodium and fluid balance. A stable diet with normal salt and adequate fluid intake helps prevent fluctuations in lithium levels and reduces risk of toxicity.
D. Avoiding aged cheese, processed meats, and red wine is teaching for MAOI therapy (to prevent hypertensive crisis due to tyramine), not for lithium.
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