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During the assessment, the nurse observes a client who was a victim of a home
invasion abruptly stand up and begin to run out of the room in response to
hearing a loud bang. What should be the nurse's initial response?
A) The client thought there was an earthquake.
B) The client was reacting to the loud noise as a form of a flashback.
C) The client wanted to check the cause for the loud noise.
D) The client thought the assessment was concluded. Correct Answer-
Answer: B
Explanation: B) Flashbacks are the recurrence of images, sounds, smells, or
feelings from a traumatic event that are triggered by daily events such as a door
banging. The client's reaction to hearing a loud bang from a door could have
made the client recall being at home during the home invasion. The client most
likely did not think that the assessment was concluded or that there was an
earthquake. The client would not have abruptly begun to run out of the room if
checking for the source of the loud noise.
The nurse suspects a client is experiencing posttraumatic stress disorder when
what is assessed?
Select all that apply.
A) Observed family member be raped and murdered
B) Restores antique automobiles as a hobby
C) Lives with spouse and has a garden
D) Has a history of anxiety disorder
E) Recently terminated from employment Correct Answer-Answer: A, D, E
, PTSD (Pearson); Questions and Answers
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Explanation: A) Risk factors for the development of posttraumatic stress
disorder include watching others be harmed or killed, the presence of a
preexisting mental illness, and the stress associated with the loss of
employment. Engaging in hobbies and living with a spouse are not risk factors
for the disorder.
A client witnessed a violent bank robbery. What would indicate to the nurse that
the client is experiencing posttraumatic stress disorder?
Select all that apply.
A) Fear of returning to sleep
B) Excessive sleeping
C) Terrifying nightmares
D) Aggressive behavior
E) Hair pulling Correct Answer-Answer: A, C, D
Explanation: A) Aggressive behavior, terrifying nightmares, and fear of returning
to sleep are physical characteristics of posttraumatic stress disorder. Excessive
sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
A client tells the nurse about continually reliving a situation of being robbed and
shot by a gunman. The nurse identifies the most appropriate diagnosis for this
client as being which of the following?
A) Fear
B) Anxiety