A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

The client talks constantly about the traumatic experience.

The client is constantly drowsy and sleeps 11-12 hr daily.

The client reports satisfying personal relationships with family and close friends.

The client is easily startled by loud voices.

Answer and Explanation

The Correct Answer is D

The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.

Reasons why the other choices are not answers:

Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.

Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.

Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.

Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.

A. Encourage verbalization of feelings. B. Provide an activity for diversion. C. Remain with the client. D. Have the client identify two coping skills.

Correct Answer is C

Explanation

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

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A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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