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 A
Explanation
A. Clozapine can cause agranulocytosis, a life-threatening drop in white blood cells, leaving the client highly vulnerable to infection. Flu-like symptoms (fever, sore throat, malaise) may be early warning signs and require immediate provider notification and WBC count monitoring.
B. Olanzapine commonly causes orthostatic hypotension. Dizziness when standing is expected early in treatment and can often be managed with slow position changes, not an emergency.
C. Thioridazine, like many antipsychotics, can cause sedation. Daytime drowsiness is a common side effect and not urgent.
D. Chlorpromazine may cause GI upset such as nausea and vomiting. While bothersome, it is not immediately life-threatening unless severe or persistent.
Correct Answer is A
Explanation
A. Using silence allows the patient time to process thoughts and feelings, encourages introspection, and can facilitate deeper communication during interviews.
B. While prolonged silence can sometimes make patients uncomfortable, its intentional and therapeutic use is beneficial when appropriately timed.
C. Reflecting or paraphrasing communicates understanding; silence alone does not confirm comprehension.
D. In therapeutic communication, the nurse does not have to immediately fill silence; allowing moments of quiet can be purposeful.
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