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"]

Explanation

A reason: Hallucinations. Hallucinations can be distressing and are associated with various mental health conditions, but they are not a direct indicator of suicide risk without other contributing factors.

B reason: Depression. Depression is a significant risk factor for suicide. Clients experiencing persistent sadness, hopelessness, and a lack of interest in life are at a higher risk for attempting suicide.

C reason: Delusions. Delusions, particularly those that are paranoid or nihilistic, can contribute to feelings of hopelessness and despair, increasing the risk of suicide attempts.

D reason: Catatonia. Catatonia involves motor immobility and behavioral abnormality. While it is a serious condition requiring treatment, it is not a direct indicator of suicide risk without other contributing factors.

E reason: Tinnitus. Tinnitus, or ringing in the ears, is not associated with an increased risk of suicide. It is a physical symptom that does not directly influence suicidal behavior.

A. "I agree with you. I'm sure this will never happen again." B. "This is awful. You should file charges against your partner." C. "This is clearly child endangerment. I will have to call the police." D. "I'd like to know more about what happened. Let's sit and talk."

Correct Answer is D

Explanation

A reason: "I agree with you. I'm sure this will never happen again." Agreeing with the parent without further investigation is inappropriate and does not address the potential risk to the child. The nurse should gather more information to assess the situation fully.

B reason: "This is awful. You should file charges against your partner." Suggesting that the parent file charges is premature without understanding the full context of the situation. The nurse's role is to gather information, assess the risk, and take appropriate protective actions.

C reason: "This is clearly child endangerment. I will have to call the police." While the nurse has a responsibility to report suspected child abuse, it is important to gather more information first. This response could escalate the situation without a thorough assessment.

D reason: "I'd like to know more about what happened. Let's sit and talk." This response is appropriate as it allows the nurse to gather more information about the situation in a non-confrontational manner. It helps build rapport with the parent while assessing the child's safety.

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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 a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt?

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

Explanation

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Correct Answer is D

Explanation

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