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 car crash 2 weeks ago and I have nightmares when I sleep.”.
"I was in a terrible car crash 2 years ago and I have been unable to drive a car since then.”.
"I was physically abused when I was a child and have frequent flashbacks since then.”.
"My parents fought a lot when I was a child.
The Correct Answer is A
Choice A rationale:
The client’s statement about experiencing nightmares after a car crash 2 weeks ago is consistent with acute stress disorder, which can occur within 3 days to 1 month after exposure to a traumatic event.
Choice B rationale:
This statement suggests a condition known as post-traumatic stress disorder (PTSD), which is characterized by symptoms that last longer than 1 month and cause significant impairment or distress.
Choice C rationale:
Frequent flashbacks of childhood physical abuse also suggest PTSD, not acute stress disorder.
Choice D rationale:
The feeling of leaving one’s body when hearing people yelling or fighting is indicative of a dissociative disorder, not acute stress disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Asking the client about the lethality of their plan is the most appropriate action. This allows the nurse to assess the immediate risk to the client’s safety.
Choice B rationale:
Encouraging the client to focus on the positive aspects of life may be helpful in some situations, but it does not address the immediate safety concern.
Choice C rationale:
Reassuring the client that everything is going to work out may provide temporary relief, but it does not address the immediate safety concern.
Choice D rationale:
Allowing the client time alone to self-reflect is not appropriate in this situation as it could increase the risk of self-harm.
Correct Answer is A
Explanation
Choice A rationale:
A necklace is not a risk as it does not pose a threat to the client’s safety.
Choice B rationale:
Lace-up tennis shoes are allowed as they do not pose a risk to the client’s safety.
Choice C rationale:
Nylon socks are allowed as they do not pose a risk to the client’s safety.
Choice D rationale:
Cotton underwear is allowed as it does not pose a risk to the client’s safety.
Choice E rationale:
A glass-framed picture should be taken back home as it can be broken and potentially used to harm oneself.
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