Posttraumatic Stress disorder Flashcards
A nurse admits a client with a preliminary diagnosis of acute stress disorder to the mental health unit. Which statement by the client requires the nurse’s immediate action?
a. “I just don’t think I can talk about it.”
b, “There are bruises all over my body.”
c, “I don’t have a desire to live anymore.”
d. “I haven’t been eating or sleeping for 2 days.”
c
The presence of suicidal thinking warrants the highest priority of care. The nurse must now determine the client’s level of suicide risk by asking if the client has a plan and the means to follow through with the plan. Although the bruises on the client’s body are suspicious and definitely warrant further questioning, the nurse should focus on the client’s immediate safety needs related to the suicide risk. Clients being unable or unwilling to express their feelings is commonly seen in abuse or trauma situations, but it is not the priority at this time. The client’s report of not eating or sleeping is consistent with the diagnosis; this issue is not an immediate concern. Client safety is always the care priority.
