A nurse is assessing the client 2 months after the assault.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Why are you having difficulty coping?": This question may sound accusatory and could make the client feel defensive. It is more effective to explore their feelings and concerns in a non-judgmental way.
B. "You should find a therapist who can help you.": While therapy can be helpful, this statement is directive and does not invite the client to express their feelings. It also may come across as dismissive of the client's current struggles.
C. "Everything will be okay if you give it some time.": This statement minimizes the client's feelings and may invalidate their experience. It's important to acknowledge their emotions and work with them to explore coping strategies rather than offering empty reassurances.
D. "Tell me about your support system.": This is the most appropriate response, it encourages the client to reflect on the resources and people they can rely on and provides an opportunity for the nurse to assess the client's support network and coping mechanisms.
Correct Answer is C
Explanation
A. Traumatic flashbacks: Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), not dementia. Clients with dementia may experience confusion or memory loss but not typically flashbacks.
B. Clang associations: Clang associations, which involve the use of rhyming words or sounds that are not connected in meaning, are more common in conditions like schizophrenia, not dementia.
C. Difficulty finding words: Difficulty finding words (aphasia) is a common symptom of dementia. As the condition progresses, clients often experience challenges with communication, including word-finding difficulties and trouble with speech.
D. Revenge seeking behavior: Revenge-seeking behavior is not a typical characteristic of dementia. While individuals with dementia may become agitated or exhibit behavioral changes, these are usually related to confusion or frustration, not planned revenge.
Complete the following sentence by using the lists of options.
The client is at risk of developing