A nurse is caring for a client:

The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all" In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2 to 3 hours of sleep

She feels that she is "jumpy" after the accident

I feel so sad that I can't seem to feel anything at all"

The client has returned to work at an accounting firm

Answer and Explanation

The Correct Answer is ["A","B","C"]

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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Correct Answer is ["B","C"]

Explanation

A. Suicide is a potential risk following sexual assault due to the emotional trauma that can ensue; however, it is not specific to males and therefore not the best answer in this context.
B. Depression is a common sequela of sexual assault among survivors due to the significant psychological impact of the trauma, which can lead to feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed.
C. Post-traumatic stress disorder (PTSD) is another frequent outcome of sexual assault, characterized by persistent mental and emotional stress as a result of injury or severe psychological shock. PTSD can manifest in nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event.
D. Becoming an abuser is a potential outcome for some survivors of sexual assault, but it is not one of the most common sequelae and is not supported by the literature as a primary risk for male survivors.
E. Human immunodeficiency virus (HIV) is a risk in cases of sexual assault where the transmission of bodily fluids occurs, but it is not a psychological sequela and thus not relevant to the question.
F. Chlamydia, like HIV, is a sexually transmitted infection that can be a risk in cases of sexual assault involving transmission of bodily fluids. However, it is not a psychological sequela and is not specific to the male gender in the context of sexual assault risk factors.

A. Ignore the nonverbal behavior and focus on the client's verbal messages. B. Integrate the verbal and nonverbal messages and interpret them as one. C. Ask the client's spouse to interpret the discrepancy. D. Pay close attention and document the nonverbal messages.

Correct Answer is D

Explanation

A. Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B. Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C. Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D. Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Correct Answer is D

Explanation

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

Which individual should the nurse consider at highest risk for suicide?