The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome.
What symptoms are consistent with long-term rape trauma? Select all that apply.

A Social withdrawal

B Exaggerated startle response

C Intrusive thoughts

D Avoidance of places associated with the assault

Answer and Explanation

Correct Answer : A,B,C,D

Social withdrawal: This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
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B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma. F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.

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Correct Answer is B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

A. Current vital signs. B. White blood cell count. C. 24-hour urinary output. D. Blood sugar level.

Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

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The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

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The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome.
What symptoms are consistent with long-term rape trauma? Select all that apply.