Nokea
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
- A. panic attacks
- B. anorexia
- C. suicide
- D. short-term memory loss
Correct Answer: C
Rationale: Suicide risk is the most critical to assess in PTSD due to high rates of suicidal ideation and attempts.
You may also like to solve these questions
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
- A. Staying with the client
- B. Distracting the client with television
- C. Interpreting the arterial blood gas report
- D. Encouraging the client to cough and breathe deeply
Correct Answer: A
Rationale: Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.
A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, 'I'm not having surgery. You must have the wrong person! My test results were negative. I'll be going home tomorrow.' The nurse recognizes the client's statement as indicative of which defense mechanism?
- A. Denial
- B. Psychosis
- C. Delusions
- D. Displacement
Correct Answer: A
Rationale: By definition, ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Denial is the defense mechanism that blocks out painful or anxiety-inducing events or feelings. In this case, the client cannot deal with the upcoming surgery for cancer and therefore denies the illness. Psychosis and delusions are not defense mechanisms. Displacement is the discharging of pent-up feelings on people who are less dangerous than those who initially aroused the feelings.
After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
- A. The United Way
- B. The client's local church
- C. The American Cancer Society Reach for Recovery
- D. The American Heart Association Mended Hearts Club
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
A client reports having difficulty concentrating and outbursts of anger, as well as feeling 'keyed up' all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?
- A. Social phobia
- B. Panic disorder
- C. Post-traumatic stress disorder (PTSD)
- D. Obsessive-compulsive disorder (OCD)
Correct Answer: C
Rationale: PTSD is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Panic disorders and social phobia are characterized by a specific fear of an object or situation. OCD involves some repetitive thoughts or behaviors.