A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

Decreased startle response to loud noises.

Reports uninterrupted sleep of 10 to 12 hours each night.

Reluctance to discuss the event that precipitated the distress.

Reports feelings of acute distress that began 1 to 2 weeks ago.

Answer and Explanation

The Correct Answer is C

A reason: Decreased startle response to loud noises. Clients with PTSD typically have an increased startle response due to hyperarousal. A decreased startle response would not be expected in PTSD.

B reason: Reports uninterrupted sleep of 10 to 12 hours each night. Clients with PTSD often experience sleep disturbances, including nightmares and insomnia. Reporting uninterrupted sleep is not characteristic of PTSD.

C reason: Reluctance to discuss the event that precipitated the distress. Clients with PTSD commonly avoid discussing the traumatic event as a way to avoid triggering distressing memories and emotions. This avoidance behavior is a key symptom of PTSD.

D reason: Reports feelings of acute distress that began 1 to 2 weeks ago. PTSD symptoms usually develop within three months of the traumatic event but can also emerge years later. Acute distress that began 1 to 2 weeks ago may not align with the typical onset pattern of PTSD.

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

Explanation

A reason: Slow speech. Slow speech is not typically associated with delirium. Clients with delirium often exhibit rapid and disorganized speech rather than slowed speech patterns.

B reason: Rapid mood changes. Rapid mood changes are common in delirium. Clients may quickly shift from calm to agitated or from happy to irritable, reflecting the fluctuating nature of their cognitive status.

C reason: Hallucinations. Hallucinations, particularly visual or auditory, are a common symptom of delirium. Clients may see or hear things that are not present, contributing to their confusion and distress.

D reason: Unaltered level of consciousness. Delirium is characterized by altered levels of consciousness, not unaltered. Clients may experience fluctuating alertness, from drowsiness to hyperactivity.

E reason: Restlessness. Restlessness and agitation are hallmark symptoms of delirium. Clients may become physically restless, unable to sit still, and exhibit purposeless movements.

A. The client has a serotonin deficiency. B. The client has acute bronchitis. C. The client has an elevated calcium level. D. The client is an only child.

Correct Answer is A

Explanation

A reason: The client has a serotonin deficiency. A serotonin deficiency is a known biological risk factor for major depressive disorder. Low levels of serotonin in the brain can contribute to depressive symptoms.

B reason: The client has acute bronchitis. Acute bronchitis is a respiratory condition and is not a recognized risk factor for major depressive disorder.

C reason: The client has an elevated calcium level. Elevated calcium levels can indicate hyperparathyroidism but are not specifically associated with an increased risk of major depressive disorder.

D reason: The client is an only child. Being an only child is not a recognized risk factor for major depressive disorder. Risk factors are more commonly related to biological, psychological, and environmental factors.

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A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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