Nokea
The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations should indicate to the nurse that the client may be experiencing post-traumatic stress disorder (PTSD)? Select all that apply.
- A. Irritability and sleep disturbances
- B. Flashbacks or recollections of the disaster
- C. Regression to an earlier developmental stage
- D. A feeling of estrangement or detachment from others
- E. Consistent discussion and rationalizing as to why the disaster occurred
- F. Repression or the inability to remember an important aspect associated with the disaster
Correct Answer: A,B,D,F
Rationale: PTSD involves recurrent flashbacks, irritability, sleep disturbances, estrangement, and repression of trauma-related memories. Regression and rationalizing the event's cause are not typical PTSD symptoms. These manifestations indicate a sustained maladaptive response to the traumatic event, often with avoidance of trauma-related stimuli and psychological distress.
You may also like to solve these questions
A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action should the nurse encourage the client to avoid?
- A. Brushing her teeth
- B. Taking acetylsalicylic acid (aspirin)
- C. Walking long distances and climbing stairs
- D. All activities because bruising injuries can occur
Correct Answer: B
Rationale: Aspirin is an antiplatelet medication and can interact with the anticoagulant medication and increase the clotting time beyond therapeutic ranges, so avoiding aspirin is a priority. The client does not need to avoid brushing her teeth, but she should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.
The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
- A. Colorectal cancer screening should begin at age 50.
- B. Men should have a prostate-specific antigen test starting at age 55.
- C. High-density lipoprotein should be greater than 50 mg/dL for women.
- D. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle.
Correct Answer: B
Rationale: Prostate-specific antigen testing typically starts at age 50, not 55, for average-risk men. Other statements are accurate.
The nurse is planning to teach a teenage client about sexuality. What should the nurse do first?
- A. Inform the teenager about the dangers of pregnancy.
- B. Establish a relationship and determine prior knowledge.
- C. Advise the teenager to maintain sexual abstinence until marriage.
- D. Provide written information about sexually transmitted infections.
Correct Answer: B
Rationale: The first step in effective communication is establishing a relationship. By exploring the client's interest and prior knowledge, rapport is established, and learning needs are assessed. The other options may or may not be later steps, depending on the data obtained.
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
- A. Sit bolt upright in bed with the arms crossed over the chest.
- B. Lie on the side with the head of the bed at a 45-degree angle.
- C. Sit in a reclining chair tilted slightly back with the feet elevated.
- D. Sit on the edge of the bed with the arms leaning on an overbed table.
Correct Answer: D
Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.