a nurse is assessing a client who has been diagnosed with post traumatic stress disorder ptsd which symptom would the nurse expect the client to exhib a nurse is assessing a client who has been diagnosed with post traumatic stress disorder ptsd which symptom would the nurse expect the client to exhib
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?

Correct answer: B

Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.

2. In a client's history, a significant indicator suggesting marginal coping skills and the need for careful risk assessment for violence is a history of

Correct answer: chemical dependence

Rationale: A history of chemical dependence is a critical factor indicating marginal coping skills and the need for assessing the risk of violence. Substance abuse can impair judgment, increase impulsivity, and escalate the likelihood of violent behavior. It is essential to thoroughly evaluate and address substance abuse issues in clients to enhance treatment outcomes and ensure safety.

3. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

Correct answer: C

Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.

4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

5. __________ coping is largely emotion-focused and self-blaming, impulsive, or escapist.

Correct answer: A

Rationale: The correct answer is A: 'Avoidant.' Avoidant coping refers to strategies that involve avoiding the problem and focusing more on emotions. This type of coping mechanism can often lead to negative outcomes as individuals may engage in self-blaming, impulsive behaviors, or seek escapist routes rather than addressing the issue directly. Choice B, 'Ineffective,' is a broad term and does not specifically capture the characteristics described in the question. Choice C, 'Problem-focused,' is the opposite of avoidant coping as it involves actively addressing the issue at hand. Choice D, 'Flexible,' does not align with the description provided, as flexibility in coping involves adapting strategies based on the situation, not necessarily being emotion-focused, self-blaming, impulsive, or escapist.

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