When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?
"On a regular basis, do you get enough restful sleep?"
"Can we discuss what triggered your angry outburst a few minutes ago?"
"Are you experiencing a flashback of the rape right now?"
"Am I correct to say that you try to avoid certain family members?"
The Correct Answer is C
A. Sleep disturbances are common in PTSD, but they might not address the current acute symptoms the client is experiencing.
B. This question explores the immediate trigger for an outburst but might not directly address the PTSD symptoms related to the sexual assault.
C. Inquiring about flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but the question about experiencing a flashback addresses more immediate distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. This precaution helps eliminate potential means for self-harm.
B. Regular checks and verbal contact are essential to monitor the patient's safety and provide support.
C. Removing objects that could be used for self-harm is a key part of suicide precautions.
D. While this is an intensive level of observation, it might not be feasible at all times due to staffing limitations, making this choice less practical than the others.
Correct Answer is D
Explanation
A. While assessing depression is crucial, in a situation following a suicide attempt, the immediate safety of the client takes precedence.
B. While ensuring the client's nutrition is important, safety regarding the recent suicide attempt is the priority.
C. This is relevant to the situation but doesn't directly address the immediate risk of self-harm or suicide.
D. Given the client's history of a suicide attempt and the present situation, initiating measures to ensure the client's safety and prevent any further harm, such as suicide precautions, is the priority.
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