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. This focuses on problem-solving rather than acknowledging the patient’s feelings, which is not empathy.
B. This expresses the nurse’s feelings, not the patient’s, so it reflects sympathy rather than empathy.
C. This statement acknowledges the patient’s emotional experience and communicates understanding from the patient’s perspective, which demonstrates empathy.
D. This is judgmental and dismissive, showing neither empathy nor support.
Correct Answer is B
Explanation
A. Neurological assessment is important, but not the priority since opioid overdose primarily causes life-threatening respiratory depression.
B. Respiratory assessment is the highest priority because opioids suppress the respiratory center, leading to hypoventilation, hypoxia, or apnea.
C. Hepatic assessment is not the immediate concern in acute overdose.
D. Cardiovascular assessment is necessary, but respiratory status takes precedence because airway and breathing are life-sustaining priorities.
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