a female client with post traumatic stress disorder ptsd has been experiencing flashbacks which intervention should the nurse implement to help the cl
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?

Correct answer: C

Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.

2. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

3. Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

Correct answer: C

Rationale: Allowing the group to handle the situation is the best action as it promotes group dynamics and empowerment, especially since the group is in the working phase. Talking to the participant individually (A) might be seen as manipulative. Reminding the participant (B) can come across as dictatorial and may not address the underlying issue. Asking the participant to join another group (D) does not address the problem at hand and avoids the opportunity for growth and conflict resolution within the current group.

4. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.

5. A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

Correct answer: D

Rationale: Encouraging the client to discuss coping mechanisms for anxiety is a supportive approach that empowers the client to manage their symptoms. Choice A may not address the client's self-management and coping skills. Choice B suggests using anxiety medication before riding the bus, which may not be the most appropriate solution. Choice C acknowledges the anxiety but does not actively involve the client in finding solutions, unlike Choice D which promotes client empowerment and self-efficacy.

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