Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
A. The client talks constantly about the traumatic experience.
The client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
B. The client is constantly drowsy and sleeps 11-12 hr daily.
The client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
C. The client reports satisfying personal relationships with family and close friends.
The client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
D. The client is easily startled by loud voices.
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
Reasons why the other choices are not answers:
Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
Similar Questions
Which statement by the client indicates an understanding of the information provided about sertraline?
A. "I should call the provider if I experience excessive sweating and muscle twitching."
Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline. Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.
B. "This medication can cause a dry cough."
"This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
C. "I need to decrease my sodium intake while on this medication."
"I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
D. "This medication can cause harmless, temporary changes to my ability to taste and smell."
"This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.
Full Explanation
Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline.
Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.
Choice B, "This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
Choice C, "I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
Choice D, "This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.
The nurse is collecting data from a client with obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)
A. Irrational fear of certain objects
This is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.
B. Difficulty relaxing
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
C. Unaware of compulsions
This is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.
D. Rule-conscious behavior
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
E. Perfectionist behavior
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
Full Explanation
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
Option A is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.
Option C is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.
Reasons why the other options are not correct answers:
Option A: Irrational fear of certain objects is more indicative of a phobia than OCD.
Option C: Clients with OCD are usually aware of their compulsions and may even try to resist them.
A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?
A. The child was brought to the facility 30 min after the injury occurred.
This is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.
B. The child begins to cry when her arm is examined by the provider.
This is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.
C. The parents report that the child injured herself by falling off the couch.
This is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones. A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.
D. The child's examination shows a single injury.
This is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.
Full Explanation
The parents report that the child injured herself by falling off the couch.
A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.
Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.
Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.
Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.
Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.