A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart?

Acute stress disorder

General adaptation syndrome (GAS)

Posttraumatic stress disorder (PTSD)

Alarm reaction

Answer and Explanation

The Correct Answer is C

Choice A reason: Acute stress disorder occurs within one month of trauma, with symptoms like nightmares and dissociation. However, symptoms persisting beyond one month, as in this case, indicate PTSD. The patient’s presentation aligns with chronic trauma effects, making PTSD the more likely diagnosis over acute stress disorder.

Choice B reason: General adaptation syndrome describes the body’s physiological response to stress (alarm, resistance, exhaustion). It is not a psychiatric diagnosis and does not account for trauma-specific symptoms like nightmares or emotional numbing. This is unrelated to the patient’s psychological response, making it incorrect.

Choice C reason: PTSD is characterized by persistent symptoms beyond one month post-trauma, including nightmares, intrusive memories, avoidance, and emotional numbing, matching the patient’s presentation. Sexual assault is a common trigger, and the nurse would expect this diagnosis documented due to the chronicity and specificity of symptoms.

Choice D reason: Alarm reaction is the initial phase of general adaptation syndrome, involving acute stress response like fight-or-flight. It is not a diagnosis and does not explain chronic psychological symptoms like recurrent memories or emotional detachment, making it irrelevant to the patient’s trauma-related condition.

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Correct Answer is D

Explanation

Choice A reason: Jumping in to provide patient comfort, while well-intentioned, implies reactive or task-oriented actions rather than the intentional, empathetic engagement of presence. Presence involves being emotionally available, fostering trust and connection, not just addressing immediate physical needs. This choice risks misrepresenting the holistic, relational aspect of presence critical for patient and family support.

Choice B reason: Being there without an identified goal does not fully capture presence, which is purposeful in fostering emotional and spiritual support. Presence involves intentional closeness and caring, not aimless attendance. This choice underestimates the nurse’s role in creating a therapeutic environment, potentially diminishing the impact of presence on patient and family well-being.

Choice C reason: Focusing on tasks prioritizes technical care over emotional connection, contrary to presence, which emphasizes being with the patient holistically. Task-oriented care may address physical needs but neglects the relational support central to presence. This choice misaligns with the concept, risking a purely functional approach that overlooks emotional and spiritual care needs.

Choice D reason: Providing closeness and a sense of caring defines presence, a nursing action rooted in Watson’s caring theory. It involves empathetic engagement, active listening, and emotional availability, fostering trust and comfort for patients and families. This intentional connection supports holistic care, enhancing psychological well-being and coping during challenging moments like illness or end-of-life care.

A. Immediate intubation and artificial ventilation. B. Administration of naloxone (Narcan). C. Close observation of signs of opioid tolerance. D. Assessment of the patient’s pain level.

Correct Answer is B

Explanation

Choice A reason: Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.

Choice B reason: Administering naloxone is the priority for opioid overdose, as evidenced by lethargy and respiratory depression (7 breaths/min) post-morphine. Naloxone, an opioid antagonist, rapidly reverses these life-threatening effects, restoring breathing and consciousness. Prompt administration is critical in older adults, who are more sensitive to opioids, ensuring patient safety and preventing hypoxia or death.

Choice C reason: Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.

Choice D reason: Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.

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Naxlex Comprehensive Predictor Exams

A nurse is providing presence to a patient and the family. Which nursing action does this involve?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The patient has a colostomy but has not yet been able to look at it. The nurse teaches the patient how to care for the colostomy. The nurse sits with the patient and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing?

A patient diagnosed with terminal cancer asks the nurse what the criteria are for hospice care. Which information should the nurse share with the patient?

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

The nurse caring for a terminally ill patient sits down and lightly touches the patient’s hand. Which technique is the nurse using?

A nurse makes a connection with the patient when providing spiritual care. Which type of connectedness did the nurse experience?

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?