Psych Exam 2 - Ch. 16 (Trauma, Stressor-Related & Dissociative Disorders)
A patient is diagnosed with disturbed personal identity. What signs and symptoms do the nurse expect to find in the patient? (SATA)
-Feelings of unreality -Amnesia
The nurse is caring for a child with posttraumatic stress disorder (PTSD). The parents ask the nurse about psychopharmacologic interventions. What is the best response by the nurse?
"Certain medications can be taken to help minimize symptoms of PTSD." There are no FDA-approved medications for children who have PTSD. Rather, certain medications can be prescribed to help manage the symptoms of PSTD, such as anxiety or depression. There are no medications that can cure PTSD, not even with the use of natural supplements or drugs. The optimal treatment for children with PTSD is cognitive behavioral therapy, and this intervention can be used in addition to medication. p. 196
A nurse conducts an initial interview with a veteran of two tours in the war with Afghanistan. The veteran says, "Sometimes I still hear explosions but I know I am safe in my home." What is the nurse's best response?
"You are describing flashbacks. These often happen after traumatic events such as war. I'd like to arrange for you to talk more about your feelings and reactions." This veteran is describing flashbacks, a major feature of posttraumatic stress disorder (PTSD). Flashbacks are dissociative experiences during which the event is relived and the person behaves as though he or she is experiencing the event at that time. Additional evaluation and treatment is indicated. Evidence-based treatments for PTSD include trauma-focused psychotherapy that may include components of exposure or cognitive restructuring, anxiety management/stress reduction to alleviate symptoms, hypnosis, and group therapy. The symptoms this patient describes do not suggest acute stress disorder. While hearing may be damaged, treatment of PTSD has a higher priority. Reactions to traumatic events may occur years after the experience. Giving advice is a nontherapeutic communication technique. p. 304, Figure 16.2
Which statement supports the existence of a comorbid condition characteristically associated with posttraumatic stress disorder (PTSD)? (SATA)
-"Controlling my anger is a big problem for me." -"I don't have any really good friends, just acquaintances." -"Marriage doesn't work for me; I've been divorced three times." -"My partner is always upset because I can't seem to keep a job." Difficulty with interpersonal, social, or occupational relationships nearly always accompanies PTSD, and trust is a common issue of concern. Common presenting symptoms include threatening or aggressive behavior. Communicating the sadness of losing loved ones is not necessarily associated with PTSD. p. 303
Which statement regarding dissociative disorder is true? (SATA)
-Cortisol regulation is dysregulated as a result of episodic dissociative events. -Dissociation is associated with a disconnection of thoughts, emotions, and behaviors. -A feature of severe dissociation referred to as "mindflight" occurs in response to significant trauma. -Some dissociative behavior is considered normal and observed in otherwise mentally healthy individuals. Dissociation is a disconnection of thoughts, emotions, sensations, and behaviors connected with a memory with some dissociation, which is considered a normal experience for most people; however, severe dissociation or "mindflight" occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol, resulting in either too much or too little cortisol. Following exposure to violence and trauma, the parasympathetic response triggers a hypoaroused state, resulting in dissociation. p. 307
How does the nurse initiate trauma intervention for a child with posttraumatic stress disorder (PTSD)? (SATA)
-Establish trust with the child in a safe environment. -Use art as a way to help the child cope with feelings. -Teach the child how to relax and gain control over thoughts and feelings. Trauma interventions for children with PTSD include using art and play as a way of helping the child cope with feelings of trauma; establishing trust and safety in the therapeutic relationship (in a safe environment); and teaching the child how to relax and gain control over thoughts and feelings before exploring the trauma. There is no need to limit or reduce the amount of play time the child has. Play can be used to help the child cope with feelings of trauma. Children should not be encouraged to talk openly about the traumatic experience; this expression should be done naturally and at a pace that is comfortable for the child. p. 301
A nurse is caring for a child diagnosed with posttraumatic stress disorder as a result of violence at home. What trauma interventions should the nurse plan for this child?
Allow the child to draw and play. Posttraumatic stress disorder usually occurs after a stressful or traumatic event. Allowing the child to draw and play would help in expression of feelings and improve the child's coping ability. When a child is traumatized due to violence at home, family involvement may disturb the child and should be avoided. The child should be allowed and trained to identify, explore, and share his or her own feelings. It can be done through activities like art and play. p. 301, Box 16.1
According to attachment theory, relationship disorders are related to trauma associated with:
Caregivers or parents Attachment patterns or schemas are formed early in life through interaction and experiences with caregivers, and this relationship is embedded in implicit emotional and somatic memories. p. 298
A nurse prepares the plan of care for a school-age child diagnosed with reactive attachment disorder. Which initial outcome should be the focus of the nurse's intervention? The child will:
Express feelings through journaling Journaling may include art or words. A school-age child is capable of self-expression using this technique. Children with reactive attachment disorder have a consistent pattern of inhibited, emotionally withdrawn behavior caused by a lack of early bonding experiences with a primary care giver. Traumatized children need to learn strategies to regulate emotion and arousal levels. Helping the child express feelings and identify emotions is essential and helps the child feel in control. Disorientation and impulsivity are not expected for a person diagnosed with reactive attachment disorder. The child should learn relaxation techniques before exploring traumatic experiences. pp. 302, 311
What information should the nurse give to the family of a patient who has had a dissociative episode?
Dissociation is a method for coping with severe stress Childhood physical, sexual, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms. p. 307
Which statement about dissociative disorders is true?
Dissociative symptoms are not under the person's conscious control. Dissociation is involuntary and results in failure of normal control over a person's mental processes and normal integration of conscious awareness. Dissociative symptoms are not a cry for attention and are not always negative. p. 307
An appropriate intervention for stage 2 of the staged model of trauma treatment is:
Engaging in memory work Appropriate interventions for stage 2 of the staged model of trauma treatment include reducing arousal and regulating emotion through symptom reduction; engaging in memory work while reducing arousal; finding comfort from others; tolerating affect; integrating disavowed emotions and accepting ambivalence, overcoming avoidance; improving attention and decreasing dissociation; working with memories; and transforming memories. p. 300
The nurse is caring for a child who has witnessed a car accident and does not remember anything that took place during the accident. Which therapy does the nurse adopt to help the child regain memory of the car accident?
Eye movement desensitization and reprocessing therapy Eye movement desensitization and reprocessing (EMDR) is an evidence-based therapy. It is an eight-phase protocol by which the child is encouraged to recollect the traumatic event by using stimulations such as audio tones. In cognitive-behavioral therapy, the nurse teaches stress management techniques to the child. In psychopharmacological therapy, medications are prescribed to the patient to treat the pathological changes caused due to stress. In dialectical developmental psychotherapy, emotion regulation techniques like meditation and deep breathing are taught to the child. p. 301
What does the nurse know about risk factors in posttraumatic stress disorder (PTSD) in children?
Good social support can help build a child's resilience to PTSD. Environmental factors can cause certain children to be more susceptible to PTSD. Therefore, children with good social support are more resilient when faced with PTSD triggers. There are environmental, biological, and psychological risk factors for PTSD. It is not accurate that all people are born predisposed to PTSD because not everyone has the same neurobiological makeup. PTSD is not a genetic condition, although there may be genetic factors that put children at higher risk of getting PTSD. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices. p. 299
Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child?
Hypervigilance Posttraumatic stress disorder in preschool children may manifest as irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance. p. 296
Empathetic listening is therapeutic because it focuses on:
Lessening feelings of isolation Empathetic listening can be healing because it can help minimize feelings of isolation. p. 311, Table 16.2
A nurse is assessing an adult patient with posttraumatic stress disorder (PTSD). Which symptom should the nurse expect to find?
Mood alterations Posttraumatic stress disorder usually follows a traumatic or stressful event and is characterized by reexperiencing, avoidance, hypervigilance, and alterations in mood. Mood alterations like chronic depression are a feature of posttraumatic stress disorder. Patients with PTSD have difficulty sleeping or are troubled by dreams of past events. Patients with PTSD often avoid talking about memories related to the past traumatic event and may have difficulty concentrating. p. 302
A 4-year-old female patient is referred to the outpatient mental health clinic after being in a severe car accident during which her father was driving and her mother died. Her father states she is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing and says repeatedly, "It's my fault because I'm bad." These behaviors support which diagnosis?
Posttraumatic stress disorder (PTSD) PTSD in preschool children may manifest as repetitive play that includes aspects of the traumatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. Children may blame themselves for the traumatic event and manifest persistent negative thoughts about themselves. Unlike PTSD, adjustment disorder may be diagnosed immediately or within three months of exposure. Responses to the stressful event may include combinations of depression, anxiety, and conduct disturbances. Dissociative identity disorder includes the presence of "alters," or other personalities that take over in times of stress. As compared with PTSD that occurs a month after the trauma, ASD occurs from three days and up to one month after exposure to a highly traumatic event. Individuals with ASD experience three or more dissociative symptoms either during or after the traumatic event, including the following: a sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (experience of a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory). p. 296
A mental health nurse plans care for four patients. These patients are diagnosed with reactive attachment disorder, disinhibited social engagement disorder, adjustment disorder, and acute stress disorder. The nurse will plan interventions designed to assist these patients to cope with:
Reactions to trauma The common feature of these disorders is exposure to trauma. Disorders included under the trauma umbrella include posttraumatic stress disorder, reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorder. Feelings of guilt, self-care deficits, and impaired social skills represent problems that may or may not be present for patients diagnosed with these disorders. pp. 302, 307
A child who is able to regain mental stability after a traumatic event is said to be:
Resilient. The term resilience refers to positive adaptation, or the ability to maintain or regain mental health despite adversity. p. 299
The nurse is caring for a patient with dissociative amnesia disorder. The patient gets extremely aggressive due to anxiety and causes physical harm to him or herself and to others. Which nursing intervention does the nurse follow to reduce anxiety and aggression in the patient?
The nurse frequently observes the patient by visiting the patient's room. The nurse frequently observes the patient to provide a protective environment by reducing the stressors. The nurse should not frequently remind the patient of past events, as it can cause severe panic and anxiety in the patient. The nurse should not be demanding or compel the patient to follow a schedule, as it can create anxiety in the patient. The nurse should help the patient in major decision-making, as the patient has reduced cognitive levels and reduced decision-making ability. It helps to lower the patient's stress and prevents the patient from making unwise decisions. p. 311, Table 16.2
A nurse is caring for an adult patient who has trauma-related disorder. The patient reports to the nurse that he has started using relaxation techniques and is sleeping better. How should the nurse interpret this behavior?
The patient is able to manage anxiety. The patient's behavior shows that the patient is able to manage anxiety, which enables the patient to sleep better and use relaxation techniques. A patient who is nervous may not sleep properly or use relaxation methods. Using relaxation techniques and having adequate sleep will make the patient more confident. Positive behaviors like maintaining eye contact and positive talk about self indicates an improvement in the patient's self-esteem. p. 303
Which statement concerning syndromes seen in other cultures, such as piblokto, Navajo frenzy witchcraft, and amok, is true?
They are culture-bound syndromes that are not dissociative disorders. Certain culture-bound disorders exist in which there is a high level of activity, a trancelike state, and running or fleeing, followed by exhaustion, sleep, and amnesia regarding the episode. These syndromes, if observed in individuals native to the corresponding geographical areas, should be differentiated from dissociative disorders. These are not physical disorders, myths, or rumors. p. 309
A patient diagnosed with posttraumatic stress disorder shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that the next medication to be prescribed will be a
Tricyclic antidepressant (TCA) TCAs or mirtazapine may be prescribed if SSRIs or serotonin-norepinephrine reuptake inhibitors (SNRIs) are not tolerated or do not work. p. 305
When does the nurse ideally conduct the initial debriefing for a patient who is admitted for severe injuries due to an accident?
Within two days of the accident The nurse conducts debriefing for a patient within two days (12-48 hours) after the accident. It helps the patient to recover from distress and to acknowledge the facts. The nurse can learn the patient's perceptions and feelings about the incident and can plan for effective treatment and care for the patient. Conducting debriefing after one week, two weeks, or six weeks after the accident may be too late. The patient develops acute stress within three days after the accident, so conducting debriefing within two days helps to reduce the symptoms of acute stress. p. 306
