A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate?
a. Document findings on the client's chart and inform the physician.
b. Perform additional assessments for post-traumatic stress disorder.
c. Educate the client on nonpharmaceutical methods to promote sleep.
d. Plan to initiate a referral to a psychologist experienced in survivor issues.
B
An individual may experience physical symptoms as a normal response to profound grief or loss, particularly after a traumatic incident. Manifestations such as insomnia, being startled easily, having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the nurse should first assess for this problem. The nurse should document assessment findings, but only after performing a more thorough assessment. A referral may be necessary, but the nurse does not have enough information yet to initiate it. If assessment reveals that methods to assist with sleep would be helpful, the nurse could provide that education.
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