Which assessment finding should the nurse expect in a client with acute stress disorder (ASD)?
Inability to remember details of the traumatic event.
A stable heart rate and blood pressure.
Euphoric mood and increased energy.
Hyperactivity and distractibility.
The Correct Answer is A
Choice A rationale:
Clients with acute stress disorder (ASD) often experience dissociation, which can lead to an inability to remember crucial details of the traumatic event. This is known as dissociative amnesia and is a hallmark symptom of ASD. The traumatic event is typically encoded in fragmented or incomplete memories due to the intense stress and emotional impact it carries.
Choice B rationale:
A stable heart rate and blood pressure (Choice B) are not typical findings in clients with acute stress disorder. ASD is characterized by an acute stress response, which often leads to physiological changes such as increased heart rate and blood pressure, not stability.
Choice C rationale:
Euphoric mood and increased energy (Choice C) are not consistent with the symptoms of acute stress disorder. ASD is more likely to cause mood disturbances like anxiety, hypervigilance, and irritability, rather than euphoria and increased energy.
Choice D rationale:
Hyperactivity and distractibility (Choice D) are not primary symptoms of acute stress disorder. While heightened arousal can occur in response to stress, hyperactivity and distractibility are more indicative of conditions like attention-deficit/hyperactivity disorder (ADHD) rather than ASD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Urging the client to "face their fears and confront that place" might overwhelm them and exacerbate their distress. Gradual exposure is a more effective approach in managing anxiety related to trauma.
Choice B rationale:
While avoidance might provide temporary relief, it reinforces the fear and prevents the client from processing the traumatic memory. Encouraging avoidance can contribute to the persistence of their symptoms.
Choice C rationale:
Gradual exposure is indeed a recommended therapeutic technique, but directly telling the client to "gradually expose themselves" might not be well received. Collaboration and guidance are important in this process.
Choice D rationale:
This response acknowledges the client's distress and suggests a collaborative approach to coping with their feelings. It opens the door for discussing coping strategies and potentially seeking professional help.
Correct Answer is C
Explanation
Choice A rationale:
Administering psychological tests is not directly related to protecting the individual's rights and promoting safety. While assessment is important, it's not a primary intervention for safeguarding rights or safety.
Choice B rationale:
Providing education about trauma prevention is valuable, but it doesn't specifically address protecting the individual's rights or ensuring their safety after the traumatic event.
Choice C rationale:
Referring the individual to appropriate services, such as therapy or counseling, can help address their emotional and psychological needs while respecting their rights. This is crucial in promoting their well-being.
Choice D rationale:
Implementing prevention strategies is essential for public health but is not the primary focus when dealing with an individual already diagnosed with acute stress disorder (ASD).
Choice E rationale:
Respecting the individual's privacy and dignity creates a therapeutic and safe environment. Trauma can make individuals feel vulnerable, and ensuring their dignity is upheld helps build trust in the therapeutic relationship.
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