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 D

Explanation

A reason: Delusion. A delusion is a false belief held despite clear evidence to the contrary. While the client's statement might reflect a distorted perception of reality, the expression of wanting to use a pen to "cut the pain out" indicates a more immediate risk of self-harm.

B reason: Hallucination. Hallucinations involve perceiving something that is not present, such as hearing voices or seeing things that are not there. The client's statement does not indicate a hallucination, but rather a desire to engage in self-harm.

C reason: Attention-seeking behavior. While attention-seeking behavior might be a consideration, the specific request to use a pen to harm themselves suggests a more severe risk of self-mutilation rather than merely seeking attention.

D reason: Self-mutilation. The client's statement clearly indicates a risk for self-mutilation. Expressing the intention to use a pen to harm themselves requires immediate intervention to ensure their safety.

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia. B. Screening college students who demonstrate manifestations of depressive disorder. C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments. D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease.

Correct Answer is B

Explanation

A reason: Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia. This action represents tertiary prevention, as it involves managing long-term symptoms and complications of an existing condition (tardive dyskinesia) in clients with schizophrenia.

B reason: Screening college students who demonstrate manifestations of depressive disorder. Screening for depressive disorders is a form of secondary prevention. It aims to identify and treat mental health conditions early before they become more severe, thus preventing further complications.

C reason: Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments. This action is an example of tertiary prevention, focusing on improving care and support for clients with existing cognitive impairments, rather than preventing the onset or progression of the condition.

D reason: Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease. This action represents tertiary prevention, as it aims to help individuals cope with the stress and challenges of caregiving for relatives with Alzheimer's disease, rather than preventing the condition itself.

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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

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, "Give me your pen to cut the pain out of my chest." The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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