A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Provide information to the client about local support groups.

Ask the client how they have dealt with stress in the past.

Determine if the client is experiencing thoughts of self-harm

Schedule a follow up visit with the client's primary provider.

Answer and Explanation

The Correct Answer is C

A. Provide information to the client about local support groups: While this is helpful, it is not the first priority. The client's immediate safety and emotional well-being must be addressed first, especially to rule out any thoughts of self-harm or suicidal ideation.

B. Ask the client how they have dealt with stress in the past: While understanding past coping strategies is important, the first priority should be assessing for immediate risks, such as thoughts of self-harm, before discussing past coping mechanisms.

C. Determine if the client is experiencing thoughts of self-harm: This is the first priority. After an assault, clients are at increased risk for self-harm or suicide. The nurse must assess for these thoughts immediately to ensure the client's safety.

D. Schedule a follow-up visit with the client's primary provider: Scheduling follow-up care is important, but it is not the first step. Immediate assessment for safety, including thoughts of self-harm, should take precedence.

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Correct Answer is ["B","C","E","F"]

Explanation

Rationale for correct choices:

Irritability: Irritability is a common symptom of posttraumatic stress disorder (PTSD), often resulting from the heightened arousal and anxiety that individuals with PTSD experience after trauma. This is frequently seen in clients who have undergone significant emotional distress.
Feelings of emptiness: A sense of emptiness or detachment is often associated with PTSD. This is related to the emotional numbness and avoidance that individuals may experience as a result of trauma, leading them to feel disconnected or emotionally "empty."
Sleep disturbance: Sleep problems, such as insomnia or nightmares, are hallmark symptoms of PTSD. Clients often struggle with restful sleep due to anxiety, hypervigilance, or intrusive thoughts related to the traumatic event.
Guilt: Guilt is a common emotion experienced by individuals with PTSD, especially following trauma such as sexual assault. Survivors may blame themselves for not preventing the event, which can contribute to their emotional distress and symptoms of PTSD.

Rationale for incorrect choices:

Hallucinations: Hallucinations are not typically associated with PTSD. While PTSD can cause intense emotional reactions, hallucinations are more commonly seen in conditions such as schizophrenia or severe substance intoxication, not in PTSD.
Echopraxia: Echopraxia, which involves mimicking another person's movements, is generally associated with conditions such as autism or certain neurological disorders, not PTSD.

A. Stay with the client for 15 min following meals B. Weigh the client every day for the first week of acute care. C. Schedule the client for a daily exercise program D. Discuss food-related topics with the client during meals.

Correct Answer is B

Explanation

A. Staying with the client for 15 minutes following meals is insufficient. The nurse should closely supervise the client for a longer duration, typically 45 to 60 minutes after every meal, to prevent them from hiding food, vomiting, or engaging in excessive physical activity to purge calories.

B. Weighing the client every day during the first week of acute care is a critical and standard intervention. Frequent weight checks are vital for monitoring initial physical stability and assessing fluid status to ensure the client is not developing refeeding syndrome, a dangerous metabolic complication that can occur during early nutritional rehabilitation.

C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.

D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.

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A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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