Choice A rationale:

The nurse's response of acknowledging the client's emotions and normalizing their feelings validates their experience. It emphasizes that such emotional responses are common after traumatic events, helping to reduce the client's distress and potentially fostering a sense of connection.

Choice B rationale:

This response might invalidate the client's emotions and rush their healing process. Telling the client that they will "get over this eventually" oversimplifies their experience and may cause further frustration.

Choice C rationale:

Advising the client to solely focus on avoiding reminders of the trauma (situations that remind them of the event) could lead to avoidance behaviors and hinder their recovery. It's important to gradually address triggers rather than completely avoiding them.

Choice D rationale:

Encouraging the client to "forget about the event completely and move on" could be dismissive of their emotional struggle. Forgetting is not a realistic goal, and suppressing emotions can be harmful in the long run.

Choice A rationale:

Urging the client to "face their fears and confront that place" might overwhelm them and exacerbate their distress. Gradual exposure is a more effective approach in managing anxiety related to trauma.

Choice B rationale:

While avoidance might provide temporary relief, it reinforces the fear and prevents the client from processing the traumatic memory. Encouraging avoidance can contribute to the persistence of their symptoms.

Choice C rationale:

Gradual exposure is indeed a recommended therapeutic technique, but directly telling the client to "gradually expose themselves" might not be well received. Collaboration and guidance are important in this process.

Choice D rationale:

This response acknowledges the client's distress and suggests a collaborative approach to coping with their feelings. It opens the door for discussing coping strategies and potentially seeking professional help.

Choice A rationale:

Administering psychological tests is not directly related to protecting the individual's rights and promoting safety. While assessment is important, it's not a primary intervention for safeguarding rights or safety.

Choice B rationale:

Providing education about trauma prevention is valuable, but it doesn't specifically address protecting the individual's rights or ensuring their safety after the traumatic event.

Choice C rationale:

Referring the individual to appropriate services, such as therapy or counseling, can help address their emotional and psychological needs while respecting their rights. This is crucial in promoting their well-being.

Choice D rationale:

Implementing prevention strategies is essential for public health but is not the primary focus when dealing with an individual already diagnosed with acute stress disorder (ASD).

Choice E rationale:

Respecting the individual's privacy and dignity creates a therapeutic and safe environment. Trauma can make individuals feel vulnerable, and ensuring their dignity is upheld helps build trust in the therapeutic relationship.

Choice A rationale:

Clients with acute stress disorder (ASD) often experience dissociation, which can lead to an inability to remember crucial details of the traumatic event. This is known as dissociative amnesia and is a hallmark symptom of ASD. The traumatic event is typically encoded in fragmented or incomplete memories due to the intense stress and emotional impact it carries.

Choice B rationale:

A stable heart rate and blood pressure (Choice B) are not typical findings in clients with acute stress disorder. ASD is characterized by an acute stress response, which often leads to physiological changes such as increased heart rate and blood pressure, not stability.

Choice C rationale:

Euphoric mood and increased energy (Choice C) are not consistent with the symptoms of acute stress disorder. ASD is more likely to cause mood disturbances like anxiety, hypervigilance, and irritability, rather than euphoria and increased energy.

Choice D rationale:

Hyperactivity and distractibility (Choice D) are not primary symptoms of acute stress disorder. While heightened arousal can occur in response to stress, hyperactivity and distractibility are more indicative of conditions like attention-deficit/hyperactivity disorder (ADHD) rather than ASD.

Choice B rationale:

Administering antianxiety medication as prescribed is the nurse's priority during the acute phase of acute stress disorder (ASD). This is because individuals with ASD often experience severe anxiety, panic attacks, and overwhelming distress. Antianxiety medications, such as benzodiazepines, can help manage the acute symptoms and provide relief from extreme anxiety.

Choice A rationale:

Encouraging the client to talk about the traumatic event (Choice A) might not be the priority during the acute phase. Revisiting the traumatic event prematurely could potentially retraumatize the client and exacerbate their symptoms.

Choice C rationale:

Assisting the client in identifying triggers for anxiety (Choice C) is an important intervention, but it may be more relevant during the later stages of treatment, when the client is more stabilized and ready to engage in cognitive-behavioral interventions.

Choice D rationale:

Providing education about relaxation techniques (Choice D) is valuable, but it might not be the top priority during the acute phase. The client's distress and anxiety levels are likely to be too high to effectively engage with relaxation techniques initially.

Choice C rationale:

The statement "I'm so relieved that my symptoms will go away within a few days" indicates a need for further education about acute stress disorder (ASD). ASD symptoms typically last for a minimum of 3 days and can persist for up to a month. This statement suggests a misunderstanding about the duration of symptoms and the potential need for appropriate interventions.

Choice A rationale:

The statement "I can't believe I'm feeling so detached from everything" (Choice A) is consistent with the emotional numbing and detachment often experienced by individuals with ASD, and it does not indicate a need for further education.

Choice B rationale:

The statement "I've been avoiding places that remind me of the trauma" (Choice B) is in line with the avoidance symptoms of ASD and does not necessarily indicate a need for further education.

Choice D rationale:

The statement "I've been having nightmares about the event" (Choice D) is indicative of the intrusive symptoms common in ASD and does not necessarily indicate a need for further education.