The nurse working with a client during a flashback says, "I know you're scared, but you're in a safe place. Do you see the bed in your room? Do you feel the chair you're sitting in?” The nurse is using which technique?

Relaxation

Grounding

Distraction

Reality orientation

Answer and Explanation

The Correct Answer is B

Choice A reason: Relaxation techniques involve calming strategies such as deep breathing or progressive muscle relaxation. The nurse’s statement is not focused on relaxation but on orienting the client to the present.

Choice B reason: Grounding is the correct technique. It helps the client reconnect with the present moment by focusing on sensory experiences, such as seeing the bed or feeling the chair. This reduces dissociation and helps the client feel safe.

Choice C reason: Distraction involves diverting attention away from distressing thoughts, often through activities or conversation. The nurse’s approach is not distraction but direct sensory grounding.

Choice D reason: Reality orientation is typically used for clients with cognitive impairment, such as dementia, to remind them of time, place, and person. In PTSD, grounding is more appropriate than reality orientation.

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Correct Answer is A

Explanation

Choice A reason: Excessive sweating and muscle twitching are potential signs of serotonin syndrome, a serious and potentially life-threatening adverse effect of sertraline and other SSRIs. Recognizing these symptoms and reporting them immediately to the provider demonstrates appropriate understanding of the medication’s risks. This response shows the client is aware of when to seek urgent medical attention.

Choice B reason: A dry cough is not a common or expected side effect of sertraline. This symptom is more often associated with ACE inhibitors used for hypertension. Associating sertraline with a dry cough reflects a misunderstanding of the medication’s side effect profile.

Choice C reason: Decreasing sodium intake is not required when taking sertraline. Sodium restriction is relevant for conditions such as hypertension or heart failure, but it is not a precaution with SSRIs. This statement shows a lack of understanding of the medication.

Choice D reason: Harmless, temporary changes to taste and smell are not typical side effects of sertraline. SSRIs are more commonly associated with gastrointestinal upset, sexual dysfunction, or sleep disturbances. This statement reflects inaccurate information.

A. Assess the client for social and family support B. Contact a social worker to report abuse. C. Ensure that the client is safe. D. Encourage the client to talk about the experience.

Correct Answer is C

Explanation

Choice A reason: Assessing for social and family support is important but not the immediate priority. Safety must be established before exploring support systems.

Choice B reason: Contacting a social worker may be necessary if abuse is suspected, but ensuring immediate safety takes precedence before involving external resources.

Choice C reason: Ensuring safety is the priority. Trauma-informed care emphasizes creating a safe environment to stabilize the client physically and emotionally. Without safety, other interventions cannot be effective.

Choice D reason: Encouraging the client to talk about the experience may be therapeutic later, but it is not the priority. Forcing discussion too early can retraumatize the client. Safety must come first.

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The nurse working with a client during a flashback says, "I know you're scared, but you're in a safe place. Do you see the bed in your room? Do you feel the chair you're sitting in?” The nurse is using which technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

Correct Answer is A

Explanation

A nurse is caring for a client who is exhibiting symptoms of emotional and physical trauma. Which of the following nursing actions is a priority when providing trauma-informed care for this client?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identify that these manifestations indicate which of the following?

A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

A nurse is collecting data from a client who reports that he has obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

A nurse assisting with the care of a child whose guardians report that the child is consistently unable to speak during class and other social situations. The nurse should identify that the child is experiencing which of the following anxiety disorders?

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?