Nokea
A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, 'I don't know how much longer I can do it. My whole life is consumed with taking care of my partner.' Which response best addresses the needs of the caregiver?
- A. How are you taking care of yourself?'
- B. Let's review your partner's diagnostic results.'
- C. I have some web-based programs for you to visit.'
- D. Your partner is lucky to have someone so devoted.'
Correct Answer: A
Rationale: The caregiver is the focus of the nurse's attention. The caregiver is suffering. The nurse must be empathetic and assess how the caregiver is caring for self. Reassurance and isolated computer activities do not help. The partner is already aware of the diagnostic results.
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A veteran of military combat tells the nurse, 'I saw a child get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind.' Which phenomenon associated with posttraumatic stress disorder (PTSD) is this veteran describing?
- A. Re-experiencing
- B. Hyperarousal
- C. Avoidance
- D. Psychosis
Correct Answer: A
Rationale: Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The veteran has described intrusive thoughts and visions associated with re-experiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.
A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are temperature (T), $98.6^{\circ} \mathrm{F}$; pulse (P), 72 beats/min (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected?
- A. T, 98.6°; P, 64; R, 14
- B. T, 98.6°; P, 68; R, 12
- C. T, 98.6°; P, 62; R, 16
- D. T, 98.6°; P, 84; R, 22
Correct Answer: D
Rationale: The patient would experience stress associated with the anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight-or-flight response) and sends signals to the adrenal glands, thereby releasing epinephrine. The circulating epinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs.
A nurse assesses the health status of veterans of the war in Afghanistan. Screening will be a priority for signs and symptoms of which health problems? (Select all that apply.)
- A. Schizophrenia
- B. Eating disorder
- C. Traumatic brain injury
- D. Seasonal affective disorder
- E. Posttraumatic stress disorder
Correct Answer: C,E
Rationale: TBI and PTSD each occur in approximately 20% of soldiers who experienced combat. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.
An individual has been diagnosed with a dissociative disorder. Which comorbid psychiatric disorders are most likely to accompany this type of mental illness? (Select all that apply.)
- A. Substance abuse disorders
- B. Depression
- C. Eating disorders
- D. Personality disorders
- E. Schizophrenia
Correct Answer: A,B,C,D
Rationale: Comorbid psychiatric disorders associated with dissociative disorders include: substance use disorders, depression and anxiety disorders, eating disorders, PTSD, and personality disorders. Schizophrenia is not associated with this type of disorder.
A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, 'Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done.' The nurse should document the patient's comment in which section of the assessment?
- A. Physical
- B. Spiritual
- C. Financial
- D. Psychological
Correct Answer: B
Rationale: Stress can be evident in a person's spirituality. This patient's comment indicates questioning of one's place in the universe and consequences for wrongdoing, both are elements of spirituality. Stress can be related to psychological, physical, or psychosocial well-being, but spirituality is the best answer.