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 hr each night.”

“Reluctance to discuss the event that precipitated the distress.”

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

Answer and Explanation

The Correct Answer is C

A. “Decreased startle response to loud noises.”: Individuals with PTSD often have an exaggerated startle response to loud noises or unexpected stimuli. This heightened startle response is a common symptom of hyperarousal associated with PTSD. Therefore, a decreased startle response would be unexpected in this context.

B. “Reports uninterrupted sleep of 10 to 12 hr each night.”: Sleep disturbances are common among individuals with PTSD. Symptoms can include difficulty falling asleep, staying asleep, or experiencing nightmares related to the traumatic event. Therefore, reports of uninterrupted sleep for 10 to 12 hours each night would be unexpected in someone with PTSD.

C. “Reluctance to discuss the event that precipitated the distress.”: Avoidance of trauma-related thoughts, feelings, or reminders is a hallmark symptom of PTSD. Individuals with PTSD often avoid discussing or thinking about the traumatic event to cope with distressing memories or emotions. Therefore, reluctance to discuss the precipitating event is a common manifestation of PTSD.

D. “Reports feelings of acute distress that began 2 weeks ago.”: PTSD symptoms typically develop shortly after experiencing a traumatic event, but the diagnosis of PTSD requires that symptoms persist for at least one month. Acute distress that began two weeks ago may indicate an acute stress reaction rather than PTSD. PTSD involves persistent symptoms beyond the acute phase of the trauma.

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Correct Answer is A

Explanation

A. “I check my breasts for lumps every day, but I’m still really scared about getting breast cancer.”: This statement reflects excessive worry about a specific medical condition (breast cancer) despite engaging in frequent checking behaviors. It is consistent with illness anxiety disorder.

B. “I have had several negative pregnancy tests but know they are all wrong.”: This statement suggests a belief that contradicts objective evidence (negative pregnancy tests) and may indicate a somatic symptom disorder or a delusional disorder rather than illness anxiety disorder.

C. “I double-check my pills because I think the pharmacist may be putting poison in them.”: This statement reflects mistrust or paranoia about medications and the intentions of the pharmacist. While it involves health-related concerns, it may be more indicative of paranoid ideation or delusional beliefs.

D. “I feel really nervous when my partner goes to work, and I am home alone during the day.”: This statement describes anxiety related to separation from a partner and being alone, which is not a characteristic feature of illness anxiety disorder. It may be more indicative of generalized anxiety disorder or separation anxiety disorder.

A. “I can hear him crying in the middle of the night.” B. "He spends most of his time locked in his room.” C. “He refuses to go to the movies with his friends.” D. “I noticed several cutting marks on both of his arms.”

Correct Answer is D

Explanation

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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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

A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has illness anxiety disorder?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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