A trauma survivor is requesting sleep medication because of "bad dreams." The nurse is concerned that the patient may be experiencing posttraumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient?
Are you reliving your trauma?
Can you tell me when you wake up?
Can you describe your phobias?
Are you having chest pain?
The Correct Answer is A
Choice A reason: Asking if the patient is reliving trauma targets a core PTSD symptom—intrusive memories or flashbacks—critical for diagnosis per DSM-5 criteria. This question helps identify PTSD’s psychological impact, guiding interventions like cognitive behavioral therapy or SSRIs. Prioritizing this ensures timely recognition of PTSD, addressing the patient’s sleep disturbances and trauma-related distress effectively.
Choice B reason: Asking when the patient wakes up provides limited insight into PTSD. While sleep timing may indicate disturbances, it doesn’t address specific PTSD symptoms like intrusive memories or hyperarousal. This question is less urgent, risking delayed identification of PTSD, which requires targeted psychological assessment to guide therapy and medication for trauma-related nightmares.
Choice C reason: Describing phobias is irrelevant to PTSD assessment, as phobias are distinct anxiety disorders. PTSD involves trauma-specific symptoms like flashbacks, not generalized fears. This question misdirects focus from trauma-related sleep issues, potentially delaying PTSD diagnosis and appropriate interventions like trauma-focused therapy, leaving the patient’s nightmares and distress unaddressed.
Choice D reason: Asking about chest pain assesses physical symptoms unrelated to PTSD’s psychological profile, which includes nightmares and intrusive thoughts. While chest pain could indicate anxiety or cardiac issues, it’s not a priority for suspected PTSD. This question risks overlooking trauma-related symptoms, delaying psychological evaluation and support critical for the patient’s mental health recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Caring touch involves physical contact to convey empathy, like holding a hand. The nurse leaves the room without touching the patient or family, overwhelmed by grief. This action does not involve physical contact or comfort, making it unrelated to caring touch in this scenario.
Choice B reason: Therapeutic touch is a healing technique using energy fields, not applicable here. The nurse’s departure due to emotional overwhelm does not involve physical or energetic interaction with the family or patient, focusing instead on self-preservation, making this an incorrect type of touch.
Choice C reason: Task-oriented touch involves physical contact for procedures, like taking a pulse. The nurse’s action of leaving the room is not task-related or physical. It reflects an emotional response to grief, not a clinical task, making this an incorrect description of the nurse’s behavior.
Choice D reason: Protective touch describes actions to shield oneself or others from emotional distress, like withdrawing from overwhelming situations. The nurse, overwhelmed by the family’s grief, leaves the room to cope, demonstrating protective touch by prioritizing emotional self-preservation, making this the correct description.
Correct Answer is B
Explanation
Choice A reason: Maturational loss occurs with normal developmental transitions, like aging or menopause. Amputation from military injuries is an unexpected event, not a developmental milestone. This type does not apply to the veteran’s sudden, trauma-related loss, making it incorrect for the care plan focus.
Choice B reason: Situational loss results from unpredictable events, like amputation due to military injuries. This loss impacts the veteran’s mobility, identity, and lifestyle, requiring targeted interventions for grief, adaptation, and rehabilitation. The nurse’s care plan should focus on addressing this situational loss to support emotional and physical recovery.
Choice C reason: Perceived loss is subjective, like loss of self-esteem, but amputation is a tangible, objective loss of limbs. While emotional impacts exist, the primary loss is physical and situational. This type is less specific to the veteran’s experience, making it an incorrect focus for the care plan.
Choice D reason: Uncomplicated loss refers to normal grief without complications, not a specific type of loss. Amputation is a complex situational loss with physical and psychological impacts. This term does not capture the nature of the veteran’s experience, making it inappropriate for the care plan focus.
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