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A nurse is assessing the client 2 months after the assault.

Exhibits

Based on the provider's diagnosis, which of the following client manifestations should the nurse expect?
Select the 4 potential findings the nurse should expect.

Hallucinations

Irritability

Feelings of emptiness

Echopraxia

Sleep disturbance

Guilt

Answer and Explanation

Correct Answer : B,C,E,F

Rationale for correct choices:

Irritability: Irritability is a common symptom of posttraumatic stress disorder (PTSD), often resulting from the heightened arousal and anxiety that individuals with PTSD experience after trauma. This is frequently seen in clients who have undergone significant emotional distress.
Feelings of emptiness: A sense of emptiness or detachment is often associated with PTSD. This is related to the emotional numbness and avoidance that individuals may experience as a result of trauma, leading them to feel disconnected or emotionally "empty."
Sleep disturbance: Sleep problems, such as insomnia or nightmares, are hallmark symptoms of PTSD. Clients often struggle with restful sleep due to anxiety, hypervigilance, or intrusive thoughts related to the traumatic event.
Guilt: Guilt is a common emotion experienced by individuals with PTSD, especially following trauma such as sexual assault. Survivors may blame themselves for not preventing the event, which can contribute to their emotional distress and symptoms of PTSD.

Rationale for incorrect choices:

Hallucinations: Hallucinations are not typically associated with PTSD. While PTSD can cause intense emotional reactions, hallucinations are more commonly seen in conditions such as schizophrenia or severe substance intoxication, not in PTSD.
Echopraxia: Echopraxia, which involves mimicking another person's movements, is generally associated with conditions such as autism or certain neurological disorders, not PTSD.

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Correct Answer is C

Explanation

A. Intellectualization: Intellectualization involves using logic or reasoning to avoid emotional response to stress, but it is not the defense mechanism demonstrated here. The client is not using abstract thinking to avoid feelings but justifying behavior.

B. Introjection: Introjection involves internalizing the beliefs or values of others, which is not what is happening in this scenario. The client is not adopting someone else’s values but rationalizing their own actions.

C. Rationalization: Rationalization is the defense mechanism the client is using. The client is justifying their drinking as a way to cope with stress, making the behavior seem reasonable or acceptable even though it may be harmful.

D. Repression: Repression involves unconsciously blocking out uncomfortable thoughts or feelings, but the client is not denying their emotions or thoughts about stress. Instead, they are justifying their behavior, which aligns more with rationalization.

A. The client does not recognize their partner, B. The client places their shoes on the wrong feet. C. The client is unable to remember their personal history D. The client engages in wandering

Correct Answer is D

Explanation

A. The client does not recognize their partner: While this is concerning, it is a common symptom of Alzheimer's disease as it progresses. However, it is not immediately life-threatening or a direct risk to the client’s safety.
B. The client places their shoes on the wrong feet: This is a typical manifestation of cognitive decline in Alzheimer's disease. While it may affect the client's independence, it is not an urgent issue that requires immediate intervention compared to other symptoms.
C. The client is unable to remember their personal history: Memory loss, especially related to personal history, is a hallmark symptom of Alzheimer's disease. Although it affects the client's cognitive function, it is not a crisis situation requiring priority intervention.
D. The client engages in wandering: Wandering is the priority concern in this scenario. It poses a significant safety risk, as the client may become lost, confused, or injured. Ensuring the client's safety by addressing wandering behavior is essential in managing Alzheimer's disease.

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A nurse is assessing the client 2 months after the assault. Exhibits Based on the provider's diagnosis, which of the following client manifestations should the nurse expect? Select the 4 potential findings the nurse should expect.

Nursing Test Bank

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Correct Answer is C

Explanation

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A nurse is assessing the client 2 months after the assault.

Exhibits

Based on the provider's diagnosis, which of the following client manifestations should the nurse expect?
Select the 4 potential findings the nurse should expect.