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. “If I drink alcohol I will become very sick.”: This statement accurately reflects the purpose of disulfiram. Disulfiram works by causing unpleasant physical symptoms, such as nausea, vomiting, and flushing, if alcohol is consumed, thereby deterring the individual from drinking.

B. “If I drink alcohol I will not be able to fall asleep.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically affect sleep patterns directly; its effects are related to the ingestion of alcohol.

C. “If I drink alcohol will lose control of my inhibitions and say something I don’t mean.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not directly affect inhibitions or speech patterns; its effects are related to physical symptoms caused by alcohol ingestion.

D. "If I drink alcohol will have severe mood swings.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically cause mood swings; its effects are related to physical symptoms induced by alcohol ingestion.

A. Autonomic dysreflexia B. Synergistic effect C. Sleep deprivation D. Delirium

Correct Answer is D

Explanation

A. Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.

B. Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.

C. Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.

D. Delirium: Delirium is a state of acute confusion and altered consciousness characterized by disturbances in attention, awareness, cognition, and perception. Visual hallucinations and impaired consciousness are common features of delirium, especially in the context of alcohol withdrawal. Delirium often occurs due to underlying medical conditions, substance withdrawal, or medication side effects.

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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 providing teaching to a client who has a prescription for disulfiram. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

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?

Correct Answer is D

Explanation

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