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 D

Explanation

A. “I agree with you I'm sure this will never happen again.”: This response dismisses the seriousness of the situation and does not address the potential risk to the child's safety. It's important not to make assumptions about future behavior without further investigation.

B. “This is awful. You should file charges against your partner.”: While it's important to address the safety of the child, suggesting legal action may escalate the situation and could potentially put the child or parent at risk. It's important to handle such situations delicately and considerately.

C. “This is clearly child endangerment. I will have to call the police.”: While the safety of the child is paramount, involving the authorities should be done cautiously and with consideration for the family's dynamics. Calling the police immediately may not always be the most appropriate first step, especially without further assessment or discussion with the parent.

D. “I’d like to know more about what happened. Let’s sit and talk.”: This response is the most appropriate. It demonstrates a non-judgmental and supportive approach while also indicating a commitment to understanding the situation further. Sitting down to talk allows the nurse to gather more information, assess the child's safety, and provide appropriate support and resources to the family.

A. Reach to recovery B. 12-step program C. Al-Anon D. Light therapy

Correct Answer is B

Explanation

A. Reach to Recovery: Reach to Recovery is a program offered by the American Cancer Society that provides support and resources to individuals facing breast cancer. While support is crucial for individuals facing cancer, it is not directly related to alcohol withdrawal.

B. 12-step program: A 12-step program, such as Alcoholics Anonymous (AA), is a widely recognized support group for individuals recovering from alcohol addiction. These programs provide a structured approach to recovery, including support from peers who have experienced similar challenges.

C. Al-Anon: Al-Anon is a support group specifically designed for family members and friends of individuals struggling with alcohol addiction. While it may not be directly applicable to the client themselves, it could be beneficial for their family members or loved ones.

D. Light therapy: Light therapy, also known as phototherapy, is a treatment used for conditions such as seasonal affective disorder (SAD) or certain types of depression. While it can be helpful for individuals experiencing mood disturbances, it is not typically recommended specifically for alcohol withdrawal.

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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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