PrepU 13

The nurse is conducting a mental health assessment of a client who has been experiencing low mood, anxiety and loss of pleasure for the past month. The client tells the nurse he comes from a "really big family." Despite this, the client tells the nurse he continues to feel alone. Select the nurse's best response.

" You can have lots of people in your social network and still feel isolated."

The nurse is working with a client who is suspected of having posttraumatic stress disorder after witnessing a violent crime. What statement by the client's spouse would suggest that the client is experiencing hyperarousal?

"My spouse always seems so irritated now, which isn't like my spouse."

A nurse is teaching a group of nursing students about the concept that long term stress causes an increase in the wear and tear on the brain and body. Which statement by the nursing student indicates understanding of this concept?

"The increase in the wear and tear on the body from stress is allostatic load."

Which individual is exhibiting signs or symptoms that are characteristic of posttraumatic stress disorder (PTSD)? Select all that apply.

- A client who has frequent nightmares about the time a fellow soldier died from an improvised explosive device -A client who is unable to relax without first barricading the client's home after a violent home invasion and assault -A client who has quit the client's job so that the client no longer has to go to the client's old office where the client was attacked and robbed -A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect

A nurse is seeing a client in the outpatient psychiatric clinic. The client reports recent job loss and tells the nurse the client is easily angered. What is the client likely suffering from?

Adjustment disorder

A client with a diagnosis of posttraumatic stress disorder (PTSD) has been brought to the emergency department (ED) by concerned family members, who state that the client is experiencing a "nervous breakdown." The ED nurse should prioritize what aspect of care during the initial care of the client?

Assessing the client's risk for self-harm and ensuring safety

The psychiatric mental health nurse is working with a client who has been diagnosed with posttraumatic stress disorder (PTSD). Assessment reveals that the client is experiencing frequent episodes of intrusion. The nurse should consequently prioritize what assessment?

Assessing the quantity and quality of the client's sleep

What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?

Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse.

A client with posttraumatic stress disorder (PTSD) tells the nurse that he often feels like he has left his body and is looking at things from a distance. The nurse interprets this as:

Dissociation

A client in a psychiatric clinic has a history of two distinct personality states. The client is also unable to remember important personal information. What is the client likely to be suffering from?

Dissociative identity disorder

Which of the following disorders involves the emergence of varying personalities in a person that is associated with stress and conflict?

Dissociative identity disorder

When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

Failure to integrate identity, memory, and consciousness

A client who was raped while a student at college seeks support from a nurse. Which are responses consistent with the client's experience? Select all that apply.

Feeling numb in social situations with men Experiencing memory gaps while at social events with men

An adult male client with a history of PTSD is brought to the emergency department (ED). The client was startled by a dog while out for a walk and kicked it. He was calm and apologetic when he presented to the triage nurse. Which is a priority nursing intervention?

Identify risks for self-harm and aggression

A client with a history of intimate partner violence has been diagnosed with posttraumatic stress disorder. The client is wholly unwilling to discuss any aspects of personal history or current mental status with the nurse. What is the nurse's best initial action?

Make efforts to demonstrate empathy to the client

A client has experienced a physcial assault and states "I keep having nightmares about it." Which intervention may be most helpful for the nurse to explore with the client at this time?

Promote discussion of the client's thoughts and feelings about the stressful event.

Eight months ago, a client was in a hotel fire and was the last person to be rescued from the roof. The client watched the client's spouse burn to death from the helicopter. The client continues to have nightmares and is fearful that the client will die in a fire. An appropriate nursing diagnosis for the client is what?

Sleep pattern disturbance related to recurrent nightmares

The psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?

Teaching the child how to interact appropriately with strangers

The nurse's assessment of a child from a dysfunctional family background suggests that the child lacks resilience. What outcome should the nurse identify after performing appropriate interventions?

The child demonstrates that the child is empowered to solve life problems

What action by a 6-year-old child would most strongly suggest a diagnosis of disinhibited social engagement disorder?

The child gives adults enthusiastic hugs immediately after meeting them

A police officer was diagnosed with posttraumatic stress disorder after attending to a violent crime scene. What aspect of the client's current health status would most likely warrant inpatient treatment?

The client alluded to "ending this misery" in a conversation with a colleague

A nurse is performing a follow-up assessment of a client who had been treated for posttraumatic stress disorder (PTSD) a year ago. The client tells the nurse that the client is not able to maintain relationships and that the relationships last for a very short time. What is the most likely reason for this problem?

The client has issues with developing trust.

A client with a diagnosis of posttraumatic stress disorder (PTSD) tells the nurse, "When things get really bad, it sometimes feels like I'm not even in my body, like I'm floating around and watching myself." How should the nurse best interpret this client's statement?

The client is likely experiencing derealization as a result of PTSD

A nurse is caring for a client with dissociative disorder. The nurse tells the client, "Hello, I'm Robin, your nurse. It is 9 o'clock in the morning now. You are in room number 303. My name is Robin, I'm your nurse." What is the most appropriate reason for the nurse to repeat this statement?

The client may need to be reoriented.

The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?

The client reports large gaps in memory of the traumatic event

Following an assessment of a client with posttraumatic stress disorder (PTSD), the nurse concludes that the client is at risk for suicide. What would be the immediate goals of management for this client?

The client will be physically safe.

A nurse works in a psychiatric clinic. A client who lost a spouse during a robbery at their home 1 month ago approaches the nurse for consultation. How would the nurse differentiate posttraumatic stress disorder (PTSD) from acute stress disorder?

The symptoms began 3 months after the trauma.

A nurse is teaching a client about how traumatic events affect a person. Which examples are included in the teaching plan? Select all that apply.

Witnessing a fatal shooting Being trapped inside a capsized boat Receiving word of a terrorist attack in a nearby community

A nurse is working in a mental health clinic and cares for various clients. Which client should the nurse recognize as having the greatest risk for the development of drug dependence?

a 12 year old girl who was raped by a family friend

A client has been diagnosed with posttraumatic stress disorder (PTSD) after witnessing an explosion at the client's industrial worksite. The client will soon begin exposure therapy, so the nurse should prepare the client for:

a visit with the therapist to the place where the explosion occurred.

A psychiatric-mental health nurse is teaching the family members of a client about strategies for engaging with their family member who has recently been diagnosed with posttraumatic stress disorder (PTSD). The nurse should encourage the client's family to:

anticipate that the client is likely to be irritable and withdrawn at times.

A nurse is at the scene of a physical attack on a client and has observed that the client is having a fight or flight response. Which signs or symptoms should the nurse expect to find during the initial assessment? Select all that apply.

heart rate 115 beats per minute blood glucose 162 mg/dl

A client continues to complain of chest pain and headaches after a disaster, even though all diagnostic tests are negative. In looking at risk factors for these symptoms, what would the nurse assess for?

post-traumatic stress disorder

The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should:

try to identify any strengths or skills that can be applied during recovery.

A client who experienced serious and repeated traumas has been diagnosed with dissociative identity disorder after being rescued from an abuser. Before caring for this client, the nurse should be prepared for:

wide variations in the personality that the client exhibits.

The nurse is planning to give health-related education to adolescents with posttraumatic stress disorder (PTSD). What topics should the nurse discuss specifically for these clients? Select all that apply.

- Have a healthy, balanced diet -Set small, specific, achievable goals -Abuse of alcohol and drugs can cause ill effects

A nurse is caring for a client who has been recently robbed at gunpoint. Which physical responses should the nurse expect to identify during the assessment? Select all that apply.

- sleep disturbances -a change in weight -muscle tension -disheveled appearance

The nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) several months ago. During a comprehensive follow-up assessment, what areas should the nurse assess? Select all that apply.

-The client's use of alcohol or other drugs -Characteristics of the client's sleep -The effect of the client's PTSD on the family

When presenting a discussion of posttraumatic stress disorder (PTSD) to a group of emergency department nurses, the psychiatric-mental health nurse provides examples of traumatic events that may precede PTSD. Which example would the nurse most likely include? Select all that apply.

Personal assault by a family member Military combat mission where there were casualties Surviving an EF 4 tornado

A nurse is caring for a client who has a diagnosis of posttraumatic stress disorder (PTSD) and has been referred for care. During the client interview, what statement by the client should the nurse prioritize for follow-up?

Sometimes I feel like I can't even cope unless I've had a few drinks to calm my nerves.

A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline?

The nurse should avoid touching the client during interactions unless necessary

A client has experienced a physcial assault and states "I keep having nightmares about it." Which intervention may be most helpful for the nurse to explore with the client at this time?

debriefing about the event

The nurse is seeing a school-aged child who has been the victim of physical abuse by a parent. The nurse recognizes that the client is more likely to experience which mental health issues in adulthood? Select all that apply.

substance misuse anorexia major depressive disorder

A client was physically assaulted 1 week ago. While interviewing the client, the client reports having trouble remembering the event and feeling as if the client is walking around in a dreamlike state. The psychiatric-mental health nurse interprets these findings as most likely associated with which condition?

Acute stress disorder

A nurse is assessing an adult client in a psychology clinic. On obtaining the history, the nurse finds that the client has lost the client's job and is thus not able to meet the financial demands of the family. In the absence of other symptoms, which is the most appropriate diagnosis for this client?

Adjustment disorder

The nurse is assessing a new client and the client's 3 year-old child. During the interview, the child clamors to sit on the nurse's lap and repeatedly tries to lean into the nurse's chest. What is the nurse's best action?

Assess the child for further signs of disinhibited social engagement disorder

The nurse is interviewing a client who has recently been diagnosed with posttraumatic stress disorder (PTSD). What action by the nurse best addresses the client's experience of intrusion?

Dialoguing with the client about the frequency and intensity of the client's nightmares

The nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?

Sleep assessment

The pediatric nurse is caring for a child who comes from an abusive background and who has been diagnosed with reactive attachment disorder. What behavior should the nurse anticipate when planning this child's care?

The child will be reluctant to engage with the nurse

A nurse is caring for a client who has chronic stress related to a long history of mentally abusive parents. Which assessment findings should the nurse anticipate the client reporting during the initial assessment? Select all that apply.

history of frequent illnesses diagnosis of bipolar disorder

A nurse is teaching a family about altered thinking patterns with PTSD. Which pattern is accurate regarding the thinking of a client who has PTSD?

negative personal beliefs

A client is diagnosed with posttraumatic stress disorder (PTSD). What questions should the nurse ask the client to elicit information about the symptoms? Select all that apply.

"Do you have recurrent and intrusive thoughts of the trauma?" "Do you feel detached from others?" "Do you get irritated by trivial issues?"

A client with posttraumatic stress disorder (PTSD) tells the nurse the client feels the client is a burden on the health care system. What would be the most appropriate response from the nurse?

"Expressing your feelings will de-stress you and we want you to get well soon."

The advanced practice psychiatric mental health registered nurse is leading a support group for adolescents who have recently experienced disruptions in their life. What participant most warrants further assessment for posttraumatic stress disorder?

An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

The advanced practice psychiatric mental health registered nurse is leading a support group for adolescents who have recently experienced disruptions in their life. What participant mostwarrants further assessment for posttraumatic stress disorder?

An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

A nurse is developing a care plan for a client who has post-traumatic stress disorder. Which intervention by the nurse is a priority?

Promote discussion of the client's thoughts and feelings about the stressful event.

A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

The adolescent expresses intense guilt for the inability to save the sibling

A college student who was the victim of an attempted sexual assault has sought care due to anxiety that is affecting every aspect of the client's life. Which characteristic of the client's situation and the client's anxiety would suggest a diagnosis of posttraumatic stress disorder (PTSD) rather than acute stress disorder?

The attack took place several months ago, and the client's anxiety has been continuous.

A client with dissociative disorder is referred for psychotherapy. What would be the main focus of therapy for this client?

To reassociate with conciousness

A nurse is contributing to the interdisciplinary care plan for a client who has been diagnosed with PTSD. Which should be included in the care plan?

Vigilant monitoring for potential indications of self-harm

The nurse assesses a 6-year-old child for posttraumatic stress disorder (PTSD). The caregiver explains that the child witnessed the mother being stabbed by a neighbor. Which is a behavior consistent with the child's diagnosis?

A two-month history of angry outbursts with minor provocation

The family members of a client with posttraumatic stress disorder (PTSD) state that they are "constantly walking on eggshells" because the client reacts so strongly to stressors that seem inconsequential to them. What is the nurse's best response?

Educate the family about the client's hyperarousal

A group of at-risk teenagers have successfully completed an outdoor training program in which they had to collaborate and conquer a number of challenges. The nurse should identify what likely outcome of this program?

Enhanced resilience for the participants

When providing care for a client diagnosed with posttraumatic stress disorder (PTSD), the psychiatric nurse assesses for comorbid mental health disorders by asking what? Select all that apply.

"Do you ever think about committing suicide?" "Has anyone ever suggested that you have an alcohol problem?" "Is depression a problem for you?" "Do you often socialize with friends?"

A nurse is counseling a client who lost family members in a cyclone but has never had therapy related to the trauma. Which statement by the client suggests that the client is likely to develop posttraumatic stress disorder (PTSD)?

"I am fine, I am going to move on."

Which statement made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms?

"I describe my feelings like I'm having an out-of-body experience."

A nurse is working in a mental health clinic. Which client statement should the nurse recognize as describing a type A personality?

"I work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself."

A nurse works in a psychiatric clinic. During a counseling session, the nurse finds that the client who has posttraumatic stress disorder (PTSD) is unable to identify the intensity of the client's emotions. The client states that extreme emotions appear out of nowhere and with no warning. What suggestion should the nurse provide to help the client get in touch with the client's emotions?

"Use a journal or a log to write down your feelings."

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

Assess the client for signs and symptoms associated with post-traumatic stress disorder

In clients with posttraumatic stress disorder (PTSD), there is marked alteration in arousal and reactivity associated with the traumatic event. Knowing this, which behaviors of a client would the nurse interpret as characteristic of PTSD? Select all that apply.

Causing self-injury Inability to concentrate on studies Shouting and throwing objects out of anger

A nurse is caring for a client with posttraumatic stress disorder (PTSD). During the assessment interview, the nurse finds that the normally calm client at times becomes very aggressive and uses abusive language. When in the aggressive state, the client fails to recognize personal information. What is this behavior indicative of?

Dissociative identity disorder

A client with posttraumatic stress disorder (PTSD) has been unable to have restful sleep since being the victim of a robbery and assault. What should the nurse recommend?

Exercising regularly, but not close to bedtime

A client has been diagnosed with posttraumatic stress disorder (PTSD) after a house fire. Which nursing intervention is most appropriate?

Facilitate the client's introduction to a support group of other people recovering from PTSD

The nurse is providing care for a client whose history of intimate partner violence has resulted in posttraumatic stress disorder (PTSD). The client has few friends and states that the client is estranged from the client's family. How can the nurse best enhance the client's social support?

Facilitate the client's participation in a support group

A nurse is caring for clients with posttraumatic stress disorder (PTSD). Negative alterations in cognition and mood associated with the traumatic event are important features of PTSD. Knowing this, which symptoms is the nurse likely to find in such clients? Select all that apply.

Having negative beliefs about oneself Inability to remember important aspects of the traumatic event Getting angry with little or no provocation

A client with posttraumatic stress disorder (PTSD) holds strong Christian beliefs. The nurse refers the client to an individual from the clergy as a part of treatment. What would be the most appropriate reason for the nurse to take this action?

It fosters resilience through allegiance to religious beliefs.

A nurse is interviewing several clients who survived a school shooting ten years ago when they were in high school. Which clients should the nurse identify as having achieved adaptation following this event? Select all that apply.

Nurse manager for the local hospital. Married, mother of three, who is a stay at home mother. Father of two who works in a tire store and has a second job as a mechanic.

A nurse is caring for a client in the hospital who was admitted for injuries sustained from an abusive spouse. The client says she's scared to leave her husband for fear he will hurt her. Which actions should the nurse plan to include in the plan of care for this client? Select all that apply.

Plan an interdisciplinary team meeting regarding this situation. educate the client on resources available to her Consult social services.

A client has just adopted a child whose traumatic history resulted in a diagnosis of reactive attachment disorder. What nursing action best addresses this child's diagnosis?

Planning activities where the client and the child can bond

A client with posttraumatic stress disorder (PTSD) has been prescribed lorazepam 1 mg SL q6h PRN. What assessment finding indicates that treatment is having the desired effect?

Reduced anxiety

The nurse is working with two children who have been apprehended from a neglectful and abusive home. Initial assessments reveal that one child is much more traumatized than the other, despite similarities in their circumstances. The nurse should consider what possible explanation for their differing responses?

The children have differing levels of resilience

A client with posttraumatic stress disorder (PTSD) is having a flashback experience of a traumatic event. The client asks the nurse if the client can hold the nurse's hand. What should the nurse interpret from this behavior?

The client benefits from supportive touch.

The nurse is assessing a client who was sexually assaulted several months ago and who has subsequently developed posttraumatic stress disorder (PTSD). The nurse observes that the client's nonverbals are closed and the client is reluctant to engage with the nurse. How should the nurse best interpret this client's behavior?

The client's trauma likely has an impact on the client's ability to trust

A client is admitted to the hospital with posttraumatic stress disorder (PTSD). When approaching the client for the first time, the nurse speaks softly and gently, in a nonthreatening manner. What is the most appropriate reason for this behavior of the nurse?

To prevent the risk of triggering fears in the client

A client has been referred for care because the client's primary care provider suspects that the client has posttraumatic stress disorder (PTSD) following a motor vehicle accident. When working with this client, the psychiatric-mental health nurse should begin by:

establishing therapeutic rapport with the client.

The nurse is performing an assessment of a client who has experienced a traumatic event. In understanding the client's ability to cope with the event, what question would the nurse ask first?

"How have you managed a stressful event before?"

Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?

Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse.

A client self-describes as being "upset for weeks" after witnessing a serious motor vehicle accident. Assessment reveals significant disruptions to the client's mood and sleep quality but not the degree that would suggest posttraumatic stress disorder (PTSD). What is the nurse's best action?

Choose interventions that address the client's adjustment disorder

The nurse is caring for a client who is a rape victim. The client has been undergoing psychotherapy for the stress the client is experiencing as a result of this incident. The client has started making accusations against family members of abusing the client. Family members insist the accusations are groundless. What may the client be experiencing?

False memory syndrome

The nurse is assessing a client with posttraumatic stress disorder (PTSD). Which would the nurse categorize as reflecting intrusion? Select all that apply.

Flashbacks Short-term memory deficits

A nurse is assessing risk for trauma and stress-related disorders for a child. Which areas are important for the nurse to ask about? Select all that apply.

Incarceration of a parent Childhood physical abuse Unexpected death of a family member Childhood exposure to mother experiencing violence

When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing which condition?

Posttraumatic stress disorder

A client with PTSD is brought to the nurse in a primary care setting with lower back pain after falling from a ladder. The client became aggressive with their partner before agreeing to come to the setting. The nurse smells alcohol on the person's breath and the client does not make eye contact or expand openly to assessment questions. Which are priority nursing assessments? Select all that apply.

Risk for self-injury Risk for aggression Risk for substance abuse

The nurse is interviewing a client who witnessed a fatal accident at the workplace and was unable to save a colleague. What assessment findings would support a diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply.

The client has nightmares about the accident The client says the client is "unable to face that place again" The client says the client's family describes the client now as "edgy" and "irritable"

The nurse is reviewing the health record of a client who developed posttraumatic stress disorder (PTSD) following a spouse's cardiac arrest and death. The health record states that the client experienced derealization during the traumatic event. What assessment finding would substantiate this statement?

The client states that the client cannot remember what happened during and immediately after the event

A client who is being treated for posttraumatic stress disorder tells the nurse, "Sometimes it's like I can't feel anything—not happiness, not sadness, not fear. Nothing." How should the nurse best interpret the client's statement?

The client's emotional numbing is a protective mechanism

A client with posttraumatic stress disorder (PTSD) is treated with psychotherapy. Which behaviors would indicate that the client is well stabilized? Select all that apply.

The client is able to express grief in a nondestructive manner. The client demonstrates an increased ability to cope with stress. The client voluntarily establishes contact with friends and family.

The nurse is interviewing a client who has been diagnosed with posttraumatic stress disorder (PTSD) after being randomly attacked with a gun. The client describes a recent event where the client panicked and jumped for cover when a car backfired on the street. How should the nurse best interpret this event?

The client is experiencing hyperarousal

A client who has been admitted for an appendectomy states, "I'm really afraid of the surgery because my mother died when she was admitted for an emergency surgery." When preparing to work with the client concerning this anxiety about the surgery, the nurse recognizes what?

The client is expressing fear about the surgery. The client's fear is the body's physiologic and emotional response to a known danger.

A nurse observes that a client who has posttraumatic stress disorder (PTSD) is startled even by small noises. What is this behavior indicative of?

The client is hypervigilant.