A patient has been hospitalized after her house was destroyed in a hurricane.
She has spent two weeks in the intensive care unit and has now been transferred to the surgical floor for continued respiratory monitoring and completion of IV antibiotic therapy.
The patient reports a pain level of 2 on a scale of 0 to 10. She requests sleeping medication, explaining that she is haunted by distressing thoughts and memories of the house collapsing, which prevent her from sleeping.
She says, “I used to be so happy before all of this happened.
Now I can’t seem to get out of this funk I am in.”. She would also prefer a quieter area of the unit as she is currently near the nurses’ station and is disturbed by the noise.
After listening to the patient’s symptoms, the nurse suspects that she likely has:

Phobia.

Acute stress disorder related to traumatic stress exposure.

Hallucinations.

Separation anxiety.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.

Choice B rationale

The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.

Choice C rationale

Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.

Choice D rationale

Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.

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

Explanation

Choice A rationale

Fresh or frozen vegetables without sauce are a great choice for someone with hypertension. Vegetables are high in fiber and low in sodium, which can help lower blood pressure. They also contain potassium, which can help balance out the negative effects of sodium.

Choice B rationale

Fruits without sauce are also a good option. Like vegetables, fruits are high in fiber and potassium and low in sodium. They also contain other heart-healthy nutrients like antioxidants.

Choice C rationale

Cottage cheese is typically high in sodium, which can raise blood pressure. Therefore, it’s not the best choice for someone with hypertension.

Choice D rationale

Pickled olives are also high in sodium, making them a poor choice for someone with hypertension.

Choice E rationale

Canned soup is another food that’s typically high in sodium. While low-sodium versions are available, fresh soup made with low-sodium broth and plenty of vegetables would be a healthier choice.

A. Reassure the client that the nurse will return after all vital signs are taken. B. Pull up a chair and sit beside the client’s bed. C. Allow the client to hold the nurse’s hand until the vital signs can be completed. D. Tell the client that he must release the nurse’s hand.

Correct Answer is B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

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Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

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

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

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