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Exhibits

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0900

Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "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." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking

requests sleeping medication for the night

keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep

can't seem to get out of this funk I am in

prefer to be in a quieter area of the unit

currently by the nurses' station

pain is 2 on a 0 to 10 pain scale

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Rationale

The client is experiencing significant psychological distress characterized by intrusive thoughts and memories related to the traumatic event (house collapsing during a hurricane). These thoughts are causing her difficulty in falling asleep and impacting her emotional well-being. Her statement about feeling unable to get out of a "funk" suggests that she may be experiencing symptoms of acute stress or post-traumatic stress disorder (PTSD). It's crucial to address her psychological distress promptly to provide support and prevent exacerbation of her symptoms.

Sleep Difficulties: The client requests sleeping medication due to her difficulty in falling asleep. Sleep disturbances are common after experiencing a traumatic event and can further contribute to emotional distress and hinder recovery. It's important to assess her sleep patterns and consider appropriate interventions, such as pharmacological sleep aids under medical supervision, to help her achieve adequate restorative sleep.

Environment: The client expresses a preference for a quieter area of the unit away from constant noise (talking and alarms). Hospital environments can be noisy and disruptive, which can exacerbate anxiety and sleep difficulties. Ensuring she is in a quieter environment or making adjustments to minimize noise near her can improve her comfort and facilitate better sleep, which is essential for recovery and emotional well-being.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorderrelated to traumatic stress

Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.

Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.

A. Obtain thickening powder before providing any more fluids. B. Assist the spouse and carefully give the client small sips of water. C. Ask the spouse to stop and assess the client's swallowing reflex. D. Give the spouse a straw to help facilitate the client's drinking.

Correct Answer is C

Explanation

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Select from the options to complete the sentence. After listening to the client's symptoms, the nurse realizes that she likely has dropdown related to dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

Correct Answer is C

Explanation

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