The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

I am at high risk for post-traumatic-stress disorder because I have acute stress disorder

I can use holistic approaches like meditation to help my symptoms.

I can learn to manage my thoughts better through therapy.

Many people have the same response to a stressful situation as I am having.

This diagnosis means that I am crazy.

I will probably need to be on medication for the rest of my life.

I am at high risk for post-traumatic-stress disorder because I have acute stress disorder

I can use holistic approaches like meditation to help my symptoms.

I can learn to manage my thoughts better through therapy.

Many people have the same response to a stressful situation as I am having

This diagnosis means that I am crazy.

I will probably need to be on medication for the rest of my life.

Answer and Explanation

The Correct Answer is ["A","E","F"]

A) Correct- The client's statement suggests a misconception about the progression from acute stress disorder (ASD) to post-traumatic stress disorder (PTSD). While ASD is an initial response to trauma, it doesn't necessarily indicate a high risk for developing PTSD. The nurse should provide education about the differences and the various factors that influence the development of PTSD.

B) Incorrect- This statement reflects the client's proactive approach to using holistic approaches like meditation to manage symptoms. Meditation and other relaxation techniques can be beneficial for managing stress and anxiety related to the traumatic event.

C) Incorrect- This statement reflects the client's motivation to learn how to manage their thoughts better through therapy. Therapy can be highly effective for addressing trauma-related distress and helping clients develop coping strategies.

D) Incorrect- This statement reflects the client's recognition that their response is shared by many people in similar situations. Validating the client's experience and normalizing their feelings can be therapeutic.

E) Correct- This statement reflects a common misconception and stigma associated with mental health diagnoses. The nurse should reassure the client that a diagnosis of acute stress disorder does not equate to being "crazy" and provide information about the nature of the disorder and available treatments.

F) Correct- The statement implies a potential pessimistic outlook on treatment. While medication might be part of the treatment plan, it's important to emphasize that treatment approaches are individualized. Encouraging an open dialogue about various treatment options, including therapy and coping strategies, is essential.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D","E","H"]

Explanation

Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.

Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.

A. Remain non-judgmental and assure the client of confidentiality. B. Provide counseling that most contraceptives protect against infection. C. Clarify that all STIs are transmitted through sexual intercourse. D. Inform the client that complications will not result from reinfection.

Correct Answer is A

Explanation

It is essential for the nurse to maintain a non-judgmental and supportive attitude when caring for clients with STIs, including genital herpes. Assuring the client of confidentiality helps to create a safe and trusting environment, encouraging open communication about the client's concerns and experiences.

This approach promotes the client's well-being and allows for effective education and support regarding STI prevention, transmission, and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

Correct Answer is ["B","C","D","E","H"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide

Correct Answer is A

Explanation

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?