PTSD (Pearson)
A client witnessed a violent bank robbery. What would indicate to the nurse that the client is experiencing posttraumatic stress disorder? Select all that apply. A) Fear of returning to sleep B) Excessive sleeping C) Terrifying nightmares D) Aggressive behavior E) Hair pulling
Answer: A, C, D Explanation: A) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
The nurse suspects a client is experiencing posttraumatic stress disorder when what is assessed? Select all that apply. A) Observed family member be raped and murdered B) Restores antique automobiles as a hobby C) Lives with spouse and has a garden D) Has a history of anxiety disorder E) Recently terminated from employment
Answer: A, D, E Explanation: A) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. What should be the nurse's initial response? A) The client thought there was an earthquake. B) The client was reacting to the loud noise as a form of a flashback. C) The client wanted to check the cause for the loud noise. D) The client thought the assessment was concluded.
Answer: B Explanation: B) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.
A client is being admitted with a diagnosis of post-traumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, the nurse anticipates the physician will order which medication? A) Propanolol (Inderal) B) Prazosin (Minipress) C) Risperidone (Risperdal) D) Fluvoxamine (Luvox)
Answer: B Explanation: B) Prazosin is an antihypertensive medication that may be prescribed for treatment and prevention of nightmares. Propanolol (Inderal) is a beta-blocker; its possible uses include management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an antipsychotic that may be used in the treatment of OCD or panic disorders. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of OCD.
What should the nurse plan for a client diagnosed with posttraumatic stress disorder who has experienced symptoms for 4 months? A) Guidelines on conducting activities of daily living B) Information on the treatments available C) Referral to local employment agency D) Information on the need for adequate exercise
Answer: B Explanation: B) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which would indicate that interventions have been beneficial for this client? Select all that apply. A) The client takes a sedative at least 4 times a day. B) The client has been sleeping throughout the night. C) The client keeps all of the lights on at home. D) The client verbalizes future plans with family and friends. E) The client will not enter a car with fewer than three people.
Answer: B, D Explanation: B) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.
A client diagnosed with posttraumatic stress disorder is experiencing insomnia. Which intervention(s) would be beneficial for this client? Select all that apply. A) Discuss the importance of exercise before sleep. B) Instruct in relaxation techniques. C) Encourage the use of sedatives. D) Suggest daytime naps. E) Coach in the use of guided imagery.
Answer: B, E Explanation: B) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation techniques and guided imagery are just two therapies found to be beneficial in clients with this disorder. Daytime naps are to be avoided. Sedatives do not produce long-term relief from insomnia and should not be encouraged. Exercise before sleep would serve as a stimulant and should not be encouraged.
Which interventions would be appropriate for a client demonstrating acute anxiety related to posttraumatic stress disorder? Select all that apply. A) Encourage the client to discuss what caused the syndrome to develop. B) Provide a calm, quiet environment. C) Give the client paperwork to complete while waiting to be assessed. D) Ask the client what is causing the anxiety. E) Reassure the client that the environment is safe.
Answer: B, E Explanation: B) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of his or her safety. The client should not be given paperwork to complete. Asking the client what is causing the anxiety and encouraging the client to discuss what caused the syndrome to develop are not effective interventions for acute anxiety related to this disorder and should not be done.
A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. The nurse identifies the most appropriate diagnosis for this client as being which of the following? A) Fear B) Anxiety C) Post-Trauma Syndrome D) Ineffective Coping
Answer: C Explanation: C) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicide ideation and a sleep disturbance due to frequent nightmares. Which goal will the nurse identify as the priority goal for this client? A) The client will report a reduction in or cessation of nightmares. B) The client will report a decreased perception of anxiety. C) The client will discuss emotions related to traumatic experiences. D) The client will remain free from injury or harm.
Answer: D Explanation: D) Assuring that the client remains free of injury would be the priority goal. The client was admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety is a priority. The other goals are relevant to the care of the client; however, they are not the priority goals.
A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicide ideation and a sleep disturbance due to frequent nightmares. Which nursing diagnosis will the nurse identify as the priority nursing diagnosis for this client? A) Disturbed Sleep Pattern B) Post-Trauma Syndrome C) Risk for Other-Directed Violence D) Risk for Self-Directed Violence
Answer: D Explanation: D) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore Risk for Other-Directed Violence would not be appropriate for this client.