Exhibits The nurse evaluates the client findings. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse evaluates the client and determines there are concerning symptoms, including subjective symptoms of dropdown and dropdown.
Explanation & Rationale
Rationale for Correct Choices: Sleeping difficulty: The client reports insomnia, a core symptom of post-traumatic stress disorder (PTSD) and depression. Sleep disturbances are common among individuals with trauma exposure and are particularly concerning when paired with suicidal ideation. Hypervigilance: The client's constant surveying of the environment and being easily startled are hallmark signs of hypervigilance. This symptom reflects heightened arousal often seen in PTSD, especially in veterans who have experienced combat trauma. Rationale for Incorrect Choices: Withdrawn mood: While the client appears quiet and withdrawn, this behavior is more observational than subjective. The question asks for subjective symptoms, which are the client’s personal experiences rather than behaviors noted by others. Alcohol on breath: The presence of alcohol on the breath is an objective clinical finding, not a subjective symptom reported by the client. Although relevant to her condition, it doesn’t fulfill the criteria specified in the prompt. Blood pressure of 144/92 mmHg: This is an objective vital sign and not a subjective symptom. Elevated blood pressure may be due to anxiety but is not something the client reports feeling. Nightmares: Though she has nightmares, this was part of the background history already acknowledged. Hypervigilance is more acute and directly observable during this clinical encounter. Latency of response: While the client requires prodding to give answers, this is an observed behavior and not a reported internal experience, so it does not qualify as a subjective symptom. Respirations of 20 breaths/minute: This is an objective clinical measurement. It may suggest anxiety, but it is not subjectively reported by the client.