The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes
The head nurse tells the staff, "You will need to assess for acute stress reactions as well as treating physical problems." Which patient is exhibiting symptoms characteristic of acute stress reaction?
a. A male whose moods swing between mania and depression
b. A female who reports still hearing her daughter's pleas for help
c. A male who keeps repeating "I don't understand what's going on?"
d. A female who is rocking her young son and repeating "it will be okay."
ANS: C
Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction.
You might also like to view...
Mary, an 85-year-old patient with cognitive impairment and gross instability, wanders conti-nuously. Lately, she has fallen twice, and the family demands that she be restrained. As the unit manager, you have initiated a least restraint practice
An appropriate action in this situation would be: a. Setting up a nursing team meeting to re-view practices. b. Calling the family to inform them of the practice. c. Initiating a multidisciplinary and family meeting to focus on Mary's needs. d. Restraining Mary to satisfy the family's wishes.
When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion?
A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-caudal
Which is not a normal finding during pregnancy?
1) Yellowing of the nails 2) Brownish coloring on face 3) Dark purple vulva 4) Darkening of nipples
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when the patient reports decreased mobility.