a client with post traumatic stress disorder ptsd is experiencing a flashback what is the nurses priority action
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?

Correct answer: B

Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.

2. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

3. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

4. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

5. A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The nurse should include which information in the client's discharge teaching?

Correct answer: B

Rationale: Corrected Rationale: Buspirone takes time to become fully effective, so the client should be informed to expect a gradual improvement in anxiety symptoms. Choice A is incorrect because buspirone is not associated with physical dependence. Choice C is not directly related to buspirone but is generally a good practice when taking any medication. Choice D is less common with buspirone compared to other anxiety medications.

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