The nurse suspects a client is experiencing acute stress disorder when which of the following symptoms are assessed? (Select all that apply.)
1. Sense of detachment
2. Internal locus of control
3. Depersonalization
4. Setting goals
5. Inability to cope
6. Hoping for a positive outcome
1, 3, 5
The following are symptoms associated with acute stress disorder: a sense of detachment or reduced awareness of surroundings; depersonalization or feelings of unreality, alienation, or amnesia; and the inability to cope effectively. Internal locus of control, setting goals, and hoping for a positive outcome are responses to positively cope with stress.
You might also like to view...
A client is being evaluated for coronary artery disease (CAD) and is scheduled for an electron beam computed tomography. The nurse understands that the primary advantage of this radiologic test is which of the following?
A) Less exposure to radiation B) Clear images C) Less invasive procedure D) Quantifies calcified plaque
A client is undergoing radiation therapy and asks the nurse about skin care for the exposed area. Which statement by the nurse is most accurate?
a. "No products work well to reduce the skin reactions you get from radiation." b. "No one product works best, so you can choose what you would like to use." c. "The only medication that works well for skin reactions is very expensive." d. "No good studies on skin care with radia-tion have been conducted to date."
The client has an endotracheal tube and is on a mechanical ventilator and the nurse establishes Ineffective airway clearance as the client's nursing diagnosis. Which is the priority nursing in-tervention for the client's nursing diagnosis?
1. Maintain airway patency. 2. Suction endotracheal tube. 3. Maintain SaO2 above 95%. 4. Check breath sounds often.
A malignant tumor:
a. Grows slowly and in a localized area b. Spreads to other parts of the body c. Invades and destroys nearby tissue d. Is not cancer