A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder?

"I was in a terrible car crash 2 years ago and I have been unable to drive a car since then

"My parents fought a lot when I was a child. Now when I hear people yelling or fighting. I feel like I left my body."

"I was in a car crash 2 weeks ago and I have nightmares when sleep

"I was physically abused when I was a child and have frequent flashbacks since then.

Answer and Explanation

The Correct Answer is C

A. This statement describes a long-term reaction to a traumatic event, which is more consistent with post-traumatic stress disorder (PTSD) rather than acute stress disorder (ASD), which occurs within 3 days to 4 weeks of a traumatic event.
B. This statement refers to dissociation related to a past trauma but doesn’t specifically indicate the timeframe for acute stress disorder, which typically involves symptoms that occur shortly after a trauma.
C. Acute stress disorder occurs within 3 days to 4 weeks of a traumatic event and can include symptoms like nightmares, intrusive thoughts, and flashbacks. This statement is consistent with ASD, which is characterized by immediate reactions to a traumatic event.
D. This statement suggests long-term PTSD symptoms (such as flashbacks) after childhood trauma, not acute stress disorder. PTSD typically develops after the symptoms persist for more than a month.

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Correct Answer is ["A","E"]

Explanation

A. Statement regarding outlook on living is a priority concern because the client stated, "I can't go on living without my child." This indicates possible suicidal ideation and requires immediate assessment and intervention for client safety.
B. Statement related to feelings of sadness and anger is an expected reaction in the grieving process. While it should be monitored, it is not an immediate safety risk and therefore not the top priority.
C. Knowledge of expectations during group meetings is related to participation in therapy, not a pressing concern that threatens the client’s wellbeing.
D. Awareness of the therapist's role shows insight and is helpful for therapy engagement, but is not urgent.
E. Statement related to use of pharmacological interventions is a priority because the client reports non-adherence to prescribed Sertraline due to a belief it won’t help. Noncompliance with medication can worsen depression and increase suicide risk, making this a key issue to address immediately.

A. Resources for group therapy in the community B. Information about insurance coverage C. Aggressiveness of potential for self-harm D. Medication compliance

Correct Answer is C

Explanation

A. Community resources are helpful for long-term support, but immediate safety takes precedence.
B. Insurance details are administrative and do not directly impact client safety or immediate care.
C. Clients with borderline personality disorder (BPD) often exhibit impulsivity, emotional instability, and may have a high risk for self-harm or suicidal behaviors. Therefore, the potential for self-injury or aggression is the nurse’s priority to address for ensuring safety.
D. While medication compliance is part of the overall treatment plan, safety concerns like self-harm come first in priority

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A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","E"]

Explanation

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Correct Answer is C

Explanation

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