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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. A client who has borderline personality disorder and exhibits splitting behaviors

While splitting behaviors can be concerning and may require intervention, they do not typically pose an immediate threat to the client's safety or well-being compared to other urgent issues such as hallucinations or medication side effects.

B. A client who has schizophrenia and reports command hallucinations

Command hallucinations can be dangerous as they may prompt the client to engage in harmful behaviors or actions directed by the hallucinations. Therefore, this client should be assessed first to ensure their safety and intervene if necessary.

C. A client who recently started taking lithium and has a fine hand tremor

A fine hand tremor is a common side effect of lithium therapy and typically does not require immediate attention unless it becomes severe or interferes significantly with the client's functioning. Therefore, this client's assessment can be prioritized lower than the client experiencing command hallucinations.

D. A client who takes nicotine and states they have a dry mouth

While a dry mouth can be uncomfortable, it is not typically a critical issue requiring immediate assessment compared to the safety concerns associated with command hallucinations in a client with schizophrenia.

A. Grandiosity B. Flight of ideas C. Splitting D. Hyperactivity E. withdrawal

Correct Answer is ["A","B","D"]

Explanation

A. Grandiosity: Individuals experiencing a manic episode may exhibit grandiosity, such as an inflated sense of self-importance, superiority, or power.

B. Flight of ideas: Flight of ideas refers to rapid, continuous speech that jumps from one topic to another, often with loose associations. It is a common manifestation of a manic episode.

C. Splitting: Splitting is a defense mechanism commonly associated with certain personality disorders, such as borderline personality disorder, but it is not typically observed during a manic episode of bipolar disorder.

D. Hyperactivity: Hyperactivity, or increased physical activity, is characteristic of a manic episode. Clients may engage in excessive goal-directed activities or restlessness.

E. Withdrawal: Withdrawal, or social withdrawal, is not a typical behavior during a manic episode. Instead, individuals with mania tend to exhibit increased sociability and extroversion.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 in an acute mental health facility receives change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

Correct Answer is B

Explanation

A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdraw which of the following conditions should the nurse identify as causing these manifestations?

A nurse is teaching the guardian of a school-age child who has autism spectrum disorder about a new prescription for risperidone. Which of the following statements by the guardian an understanding of the teaching?

A nurse is caring for a client who has dementia and insists a doll is her infant child. Which of the following behavioral management techniques should the nurse use when interacting with the client?

A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?

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?

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?