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 ["A","C","D"]

Explanation

A reason: Lack of eye contact. Children with autism spectrum disorder (ASD) often exhibit reduced or lack of eye contact, which can be a key indicator of social communication difficulties associated with ASD.

B reason: Inability to play quietly. While some children with autism might exhibit hyperactive behavior, an inability to play quietly is not a specific characteristic of ASD. It can be seen in various conditions, including attention deficit hyperactivity disorder (ADHD).

C reason: Constant spinning of a toy. Repetitive behaviors, such as spinning objects, are common in children with ASD. These behaviors provide sensory input and can be calming for the child.

D reason: Withdrawal from physical contact. Children with ASD often withdraw from physical contact due to sensory sensitivities. They might find certain touches uncomfortable or overwhelming.

E reason: Repeated voicing in clothes. Repeating phrases or sounds, known as echolalia, is common in ASD, but "repeated voicing in clothes" does not accurately describe this behavior. It seems like a typographical error.

A. Provide additional attention to the client. B. Apply mechanical restraints before administering medication. C. Obtain a verbal contract from the client. D. Limit staff members who work with the client.

Correct Answer is C

Explanation

A reason: Provide additional attention to the client. While providing support and attention is important, it can reinforce attention-seeking behaviors in clients with borderline personality disorder. The care plan should balance support with boundaries.

B reason: Apply mechanical restraints before administering medication. Using restraints as a first-line intervention is not appropriate and should be avoided unless there is an immediate risk of harm. Less restrictive measures should be used initially.

C reason: Obtain a verbal contract from the client. A verbal contract, or a no-harm agreement, can be an effective strategy to engage the client in their own safety plan and reduce the risk of self-mutilation. It encourages the client to commit to seeking help before engaging in self-harm.

D reason: Limit staff members who work with the client. Consistency in care is important for clients with borderline personality disorder to build trust and maintain clear communication. Limiting staff changes helps provide stable and predictable care.

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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?

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Naxlex Comprehensive Predictor Exams

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