The Point Chapter 13
A nurse's colleague expresses sympathy for a client who is traumatized following a terrorist attack 1 week earlier. The colleague states, "I'm certain that the client has posttraumatic stress disorder (PTSD)." What is the nurse's best response? "If the client doesn't receive treatment right away, the client might not recover from the PTSD." "Actually, she won't meet the diagnostic criteria for PTSD until 3 months after the attack." "It's more likely that the client is experiencing anxiety, which will likely decrease with time." "Acute stress disorder is a possibility, which might develop into PTSD."
"Acute stress disorder is a possibility, which might develop into PTSD."
The nurse teaches a client about social support. Which example of emotional support does the nurse include in the teaching session? "Being able to confide in your spouse is an example of emotional support." "Allowing a friend to help with your sick mom is an example of emotional support." "Accepting a loan from someone is an example of emotional support." "Providing feedback to a friend is an example of emotional support."
"Being able to confide in your spouse is an example of emotional support."
The nurse is assessing a client who has been referred for disturbed sleep due to increased anxiety and low mood. In order to determine the role of emotions in the client's stress response, the nurse should ask which question? "Do you think you need an antidepressant to make you happy?" "Are you able to reach homeostasis with your emotions?" "Have you been coping with your low mood over the last few weeks?" "Can you tell me how you have been feeling most of the time for the past month?"
"Can you tell me how you have been feeling most of the time for the past month?"
The nurse assesses a new client's social network. Which question does the nurse ask to determine the client's level I contacts? "Do you see your mail carrier on Saturdays when you are not at work?" "Do you have friends whom you see on a regular basis?" "Do you have anyone whom you consider as a close personal contact?" "Do you engage with the cashier when you are at the store?"
"Do you have anyone whom you consider as a close personal contact?" A social network may be large, consisting of numerous family and community contacts, or small, consisting of few members. Contacts can be categorized according to three levels: (1) level I consists of 6 to 12 people with whom the person has close contact; therefore, the question the nurse asks to determine the client's level I contacts is "Do you have anyone whom you consider a close personal contact?" Level II consists of a larger number of contacts whom the client sees regularly; therefore, the question "Do you have friends that you see on a regular basis?" assesses this level of contacts. Engaging with the cashier at a store or seeing a mail carrier on Saturdays are examples of level III contacts.
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?" "Have you taken anti-anxiety medication in the past?" "Have you been able to go back to work?" "Has your family been supportive of you?"
"How have you managed a stressful event before?"
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 don't know what to do without my family." "I feel lonely without my parents." "I don't feel like eating without my son." "I am fine, I am going to move on."
"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 feel guilty that I survived the attack and my friend didn't." "Loud noises always make me a little jittery now." "I describe my feelings like I'm having an out-of-body experience." "It's like I'm having flashbacks every time I fall asleep."
"I describe my feelings like I'm having an out-of-body experience."
The nurse includes information regarding methods to enhance sleep for a client who experiences insomnia due to posttraumatic stress disorder (PTSD). Which client statement indicates a need for additional teaching regarding sleep hygiene? "I will maintain the same sleep schedule 7 days a week." "I will avoid caffeinated beverages during the late afternoon and early evening hours." "I have found that drinking a glass or two of wine every night helps me to fall asleep." "I will avoid taking naps during the day."
"I have found that drinking a glass or two of wine every night helps me to fall asleep."
The nurse assesses a client's ability to cope with stress. Which client statement indicates a type B personality, thus decreasing the likelihood for risky health behaviors in response to stress? "I am used to feeling like the cup of my life is half empty." "I avoid conflict like it is the plague." "I feel tense and restless a lot because I am so competitive." "I take a relaxed approach to most issues."
"I take a relaxed approach to most issues."
A nurse is working in a mental health clinic. Which client statement should the nurse recognize as describing a type A personality? "I don't let my emotions out around my co-workers or family. Nothing ever goes right for me!" "I work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself." "I'm a very relaxed person. Whatever everybody else wants is fine with me." "I just agree with whatever my co-workers say so nobody will be upset with me."
"I work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself."
The nurse is seeing a male client who is experiencing anxiety and having difficulty managing anger. The client tells the nurse he received an email last week in which a co-worker was insulting and dismissive. The client states he had difficulty sleeping after receiving the email. Select the nurse's best response. "Have you considered using a sleep medication to help initiate sleep during stressful times?" "Have you always had a bad relationship with this co-worker?" "Would you be interested in learning some assertive communication skills?" "Is there any other way in which can you interpret what the co-worker said in the email?"
"Is there any other way in which can you interpret what the co-worker said in the email?"
The nurse provides care to a client who states, "I recently separated from my spouse." Which response by the nurse is appropriate when assessing the client's emotional state during the psychosocial assessment? "Have you recently lost or gained weight?" "Let's discuss your dietary intake." "Let's discuss how you have been feeling." "Are you having trouble sleeping?"
"Let's discuss how you have been feeling."
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 seems to overeat at almost every meal, and then snack all the time too." "My spouse's libido has completely dropped off, and that's not at all like my spouse." "My spouse always seems so irritated now, which isn't like my spouse." "My spouse seems to sleep and sleep, even when there's no reason why my spouse should be tired."
"My spouse always seems so irritated now, which isn't like my spouse."
A nurse is teaching a class on type D personalites. Which statement by a student indicates an understanding of this instruction? "Pessimism is a key quality with this personality." "I would describe this person as one who has an easygoing personality." "A person with this type of personality is a people-pleaser, who does not like conflict." "A person with this personality is full of ambition."
"Pessimism is a key quality with this personality."
A nurse is educating a client about heart disease and stress. The nurse knows that the client understood the teaching when he/she states: "Stress can be felt as painful, which can harm the person with a chronic disease." "Stress does not cause any changes to your body." "Stress can affect your body's immune system, which can increase the symptoms of your disease." "Stress can not cause heart disease."
"Stress can affect your body's immune system, which can increase the symptoms of your disease."
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." "The long term wear and tear on the body by stress is reversed as the stress decreases." "Adaptation is the result of the chronic stress on the body." "This process is called homeostasis."
"The increase in the wear and tear on the body from stress is allostatic load."
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 grounding techniques to diminish the feelings." "Practice deep-breathing exercises to distract yourself from the feelings." "Use a journal or a log to write down your feelings." "Practice relaxation techniques to reduce intensity or diminish the feelings."
"Use a journal or a log to write down your feelings."
The nurse is seeing a client who is the primary caregiver for a parent with dementia. The client reports having a low mood and anxiety. The client tells the nurse, "I think I am completely burnt out." Select the nurse's best response. "What has helped you in the past when you have felt like this?" "Can other family members step in to look after your parent?" "Should you be taking anti-anxiolytic medication to manage these feelings?" "Do you think it is time to send your parent to a respite caregiver?"
"What has helped you in the past when you have felt like this?"
Which individual is exhibiting signs or symptoms that are characteristic of posttraumatic stress disorder (PTSD)? Select all that apply. 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 client who is fixated on getting revenge on the business partner whom the client blames for the client's bankruptcy A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect 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 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
Which clients would likely require inpatient treatment? Select all that apply. A client who has hyperarousal following a motor vehicle accident A client with adjustment disorder after job loss A client with posttraumatic stress disorder who is overwhelmed by flashbacks A client who is finding it difficult to cope with the loss of a job A client with posttraumatic stress disorder who has suicidal thoughts
A client with posttraumatic stress disorder who is overwhelmed by flashbacks A client with posttraumatic stress disorder who has suicidal thoughts
Which client should the nurse assess most closely for signs and symptoms of posttraumatic stress disorder (PTSD)? A business owner who has just gone through bankruptcy A registered nurse who has provided care in an urban emergency department for several years A client who has recently undergone radiotherapy and chemotherapy for cancer A service member in the military who has recently returned from two tours of duty
A service member in the military who has recently returned from two tours of duty
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 An adolescent who states "I've lost my soulmate" after the death of a boyfriend or girlfriend in an accident An adolescent who began smoking in the weeks after discovering a dead body in a park An adolescent who often redirects the conversation to the subject of the adolescent's sister's death
An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother
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? Educate the family about the usual emotional responses to returning home from military service Assess the client for signs and symptoms associated with post-traumatic stress disorder Organize a family meeting where family members can tell the client how they feel Educate the family about the relationship between hyperarousal and emotional distance
Assess the client for signs and symptoms associated with post-traumatic stress 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 Assessing the client's current drug regimen and allergy status Identifying the client's coping ability and functional status Developing therapeutic rapport with the client and family
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 client's communication skills Assessing the client's vital signs Assessing the quality of the client's support network Assessing the quantity and quality of the client's sleep
Assessing the quantity and quality of the client's sleep
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 client's vital signs Assessing the quantity and quality of the client's sleep Assessing the client's communication skills Assessing the quality of the client's support network
Assessing the quantity and quality of the client's sleep
A nurse is reviewing the medical records of several clients who have come to the community health center. The nurse would most likely identify a client experiencing which event as being at risk for developing posttraumatic stress disorder (PTSD)? Select all that apply. Watching televised segments of the moment when the plane hit the second tower on 9/11 Being stranded at the office during a typical winter storm that was anticipated Being a marine in a combat situation where the entire platoon was wiped out, except for one person Being a survivor of a tsunami that resulted in thousands of deaths Being hidden in a closet and hearing the entire family murdered by someone who broke into the home
Being a survivor of a tsunami that resulted in thousands of deaths Being a marine in a combat situation where the entire platoon was wiped out, except for one person Being hidden
A nurse is reviewing the medical records of several clients who have come to the community health center. The nurse would most likely identify a client experiencing which event as being at risk for developing posttraumatic stress disorder (PTSD)? Select all that apply. Being hidden in a closet and hearing the entire family murdered by someone who broke into the home Being stranded at the office during a typical winter storm that was anticipated Watching televised segments of the moment when the plane hit the second tower on 9/11 Being a survivor of a tsunami that resulted in thousands of deaths Being a marine in a combat situation where the entire platoon was wiped out, except for one person
Being a survivor of a tsunami that resulted in thousands of deaths Being a marine in a combat situation where the entire platoon was wiped out, except for one person Being hidden in a closet and hearing the entire family murdered by someone who broke into the home
Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate? The risk of developing PTSD following leukemia treatment is about the same as all children of the same age. Children who were abused during childhood are more likely to be diagnosed with obsessive-compulsive disorder rather than PTSD. In a family unit where one child is diagnosed with cancer, all the children in the household are at increased risk for developing PTSD. Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse.
Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse.
The nurse is seeing a female client who has improved mood and anxiety after being diagnosed with depression. The client tells the nurse she believes she will be able to remain free of depression by adhering to lifestyle changes and treatment. In this case, the client is exhibiting which type of emotion? Nonemotion Borderline Positive Negative
Borderline Borderline emotions are somewhat ambiguous: hope, compassion, empathy, sympathy, and contentment. Nonemotions connote emotional reactions but are too ambiguous to be confidence, awe, confusion, or excitement. Positive emotions occur when there is movement toward or attainment of a goal: happiness, pride, relief, and love. Negative emotions occur when there is a threat to, delay in, or thwarting of a goal or a conflict between goals: anger, fright, anxiety, guilt, shame, sadness, envy, jealousy, and disgust.
A client is diagnosed with posttraumatic stress disorder (PTSD). When assessing the client, which finding would the nurse identify as intrusive? Select all that apply. Client relates no longer experiencing dreams Client complains of excessive sleeping, usually 12 hours or more per day Client states feelings that the event is reoccurring Client reports feelings of being suspended in outer space and unable to find a way home Client reports reexperiences a traumatic image
Client reports reexperiences a traumatic image Client states feelings that the event is reoccurring Client reports feelings of being suspended in outer space and unable to find a way home
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. Consult social services. Plan an interdisciplinary team meeting regarding this situation. educate the client on resources available to her Confront the husband about the abuse. Educate the client and husband on the effects of spousal abuse.
Consult social services. Plan an interdisciplinary team meeting regarding this situation. educate the client on resources available to her
The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). Which symptom would the nurse categorize as reflecting intrusion? Select all that apply. Flashbacks Short-term memory deficits Aggressive behavior Irritability Difficulty sleeping
Difficulty sleeping Flashbacks
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 amnesia Depersonalization disorder Dissociative identity disorder Avoidance behavior
Dissociative identity disorder
Which of the following disorders involves the emergence of varying personalities in a person that is associated with stress and conflict? Depersonalization disorder Dissociative fugue Dissociative identity disorder Dissociative amnesia
Dissociative identity disorder
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? Acute stress disorder Derealization disorder Dissociative identity disorder Dissociative amnesia
Dissociative identity disorder Dissociative identity disorder is one of the dissociative disorders characterized by disruption of the integrated functions of consciousness, memory, identity, or environmental perception. In dissociative identity disorder, the client may assume two or more distinct identities that recurrently take control of the client's behavior. The client may also be unable to remember important personal information that is of a stressful nature. Dissociative amnesia is characterized by a fugue experience in which the client moves to a new geographical location, with no memory of past events. Derealization disorder is characterized by a feeling of being detached from one's mental processes or body. Acute stress response occurs in response to a stressful event and is characterized by reexperiencing, hyperarousal, and avoidance.
The school health nurse is offering community education to adolescents regarding the impact of stress on the body. When providing information about the body's physiological response to stress, the nurse should include which point? A high allostatic load is a sign that a person's immune functioning is strong. General adaptation syndrome refers to the choices people make to cope with stress. Dysregulation of the body's autonomic responses is the result of prolonged exposure to cortisol. The parasympathetic nervous system is responsible for activating the HPA axis.
Dysregulation of the body's autonomic responses is the result of prolonged exposure to cortisol.
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? Assess each member of the family for signs and symptoms of PTSD Educate the family about the client's hyperarousal Arrange for respite so that the family can have their emotional needs met Educate the family about the need to set limits assertively but empathically
Educate the family about the client's hyperarousal
The nurse is preparing to perform the initial interview of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What action should the nurse prioritize during this interaction? Eliciting the details of the traumatic event Establishing therapeutic rapport with the client Educating the client about basic coping strategies Reassuring the client that recovery will occur
Establishing therapeutic rapport with the client
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? Adopting later times for going to bed and waking up Limiting naps to times earlier than 3:00 p.m. Exercising regularly, but not close to bedtime Temporarily moving to a new bedroom, if possible
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? Focus on the client's hopes and plans for the future during interviews and other interactions Help the client to explore complementary and alternative therapies to prevent dependence on medications Arrange a consult with an occupational therapist to manage the client's return to work Facilitate the client's introduction to a support group of other people recovering from PTSD
Facilitate the client's introduction to a support group of other people recovering from PTSD
A client has been experiencing intense stress following the bankruptcy of the client's high-profile business. When asked by the nurse to describe the client's coping strategies, the client states, "Just the bottle, really." In addition to performing additional assessments, what action should the nurse prioritize? Encouraging regular exercise and a nutritious diet Facilitating a referral to a mental health specialist Arranging an intervention with trusted friends and family Teaching the client about the physiological effects of alcohol
Facilitating a referral to a mental health specialist
When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what? Disinhibited social engagement, being overly friendly with strangers Failure to integrate identity, memory, and consciousness Total amnesia of the events that caused the disorder Overuse of sedatives like alcohol
Failure to integrate identity, memory, and consciousness
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. Abuse of alcohol and drugs can cause ill effects Have a healthy, balanced diet Be spontaneous, look for new experiences Avoid social gatherings with strangers Set small, specific, achievable goals
Have a healthy, balanced diet Set small, specific, achievable goals Abuse of alcohol and drugs can cause ill effects
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. Inability to remember important aspects of the traumatic event Seeking company of others Having negative beliefs about oneself Trying to help people who have been victims of the traumatic incident Getting angry with little or no provocation
Having negative beliefs about oneself Getting angry with little or no provocation Inability to remember important aspects of the traumatic event
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. Trying to help people who have been victims of the traumatic incident Seeking company of others Getting angry with little or no provocation Having negative beliefs about oneself Inability to remember important aspects of the traumatic event
Having negative beliefs about oneself Getting angry with little or no provocation Inability to remember important aspects of the traumatic event
An adult 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. The client was calm and apologetic when presenting to the triage nurse. Which is a priority nursing intervention? Explore the origins of the client's PTSD. Observe in a locked interview room. Identify risks for self-harm and aggression. Administer a benzodiazepine medication.
Identify risks for self-harm and aggression.
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 helps the client concentrate on the therapy. It fosters resilience through allegiance to religious beliefs. It helps the client sleep in peace. It helps the client forget the traumatic incident.
It fosters resilience through allegiance to religious beliefs.
A nurse is interviewing a client who is suffering from posttraumatic stress disorder (PTSD). Which intervention would help the nurse ensure the client's comfort during the interview? Ask the client to describe the traumatic event in detail. Keep environmental noises to a minimum. Instruct the client not to move around in the room. Sit close to the client to facilitate effective communication.
Keep environmental noises to a minimum.
The nurse provides education to a group within the community regarding social networks. Which participant statement indicates a need for additional education? "My social network will not influence the course my diabetes takes." "My social network enhanced my ability to cope with my recent divorce." "I have a large social network that increases the support that is available to me." "I have an identity within my social network."
My social network will not influence the course my diabetes takes."
A nurse is teaching a family about altered thinking patterns with posttraumatic stress disorder (PTSD). Which pattern is accurate regarding the thinking of a client who has PTSD? Trust of people Grandiose perceptions Expressions of joy Negative personal beliefs
Negative personal beliefs
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? Teaching the client about the factors that cause resilience Teaching the client how to provide culturally safe care for the child Planning activities where the client and the child can bond Modeling interactions that address disruptive behavior disorders
Planning activities where the client and the child can bond
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? Emotional numbness Posttraumatic stress disorder Dissociative amnesia Paranoia
Posttraumatic stress disorder
The nurse is seeing a female client who has been experiencing stress due to financial pressure. The client tells the nurse she found a second job so that she earn additional income. The nurse recognizes the client is using which coping style? Emotion focused Reappraisal Adaptation Problem focused
Problem focused
A parent of a 4-year-old child approaches the nurse in a psychiatric clinic. The parent conveys that the child does not interact with others outside the home. When the nurse tries to talk to the child, the child averts eye contact and walks away. On further interviewing, the nurse finds that the child's father abuses alcohol and is physically violent toward the mother. What condition is the child most likely to have? Reactive attachment disorder Posttraumatic stress disorder Acute stress disorder Adjustment disorder
Reactive attachment disorder
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. I understand why I feel this way, but that certainly doesn't make it any easier. I've never been a person who has trouble sleeping, but I wake up so early in the morning these days. I thought I could do this on my own, but I can see now why the doctor suggested medication.
Sometimes I feel like I can't even cope unless I've had a few drinks to calm my nerves.
During an assessment of a client who is experiencing stress related physiologic symptoms, the nurse recognizes which symptoms the client is having are dermatologic? Nausea Sweating Increased pulse Fatigue
Sweating
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? Role modeling conflict management with the child Teaching the child how to manage disruptive thoughts of trauma Teaching the child how to interact appropriately with strangers Teaching the child how to set boundaries in familial relationships
Teaching the child how to interact appropriately with strangers
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 The adolescent often begins crying when discussing the tragedy The adolescent is fixated on having a fire escape plan in the family's new home The adolescent idealizes the relationship that the adolescent had with the sibling
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 was an isolated, rather than ongoing, event. The attack took place several months ago, and the client's anxiety has been continuous. Complementary and alternative therapies have failed to resolve the client's anxiety. Concerns for the client's safety have caused the client to change daily routines.
The attack took place several months ago, and the client's anxiety has been continuous.
What action by a 6-year-old child would most strongly suggest a diagnosis of disinhibited social engagement disorder? The child tells the nurse "secrets" during their initial meetings The child claims to have dozens of friends but no "best friend" The child has several friends that are much older or much younger than the child The child gives adults enthusiastic hugs immediately after meeting them
The child gives adults enthusiastic hugs immediately after meeting them
The nurse is assessing a 6-year-old child who witnessed the murder of the child's parents. The nurse suspects that the child has developed posttraumatic stress disorder (PTSD). Which specific behavioral manifestation leads the nurse to interpret this? The child is easily startled and hyper-vigilant. The child enjoys watching violent scenes on television. The child constantly weeps. The child avoids eating.
The child is easily startled and hyper-vigilant.
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 dissociative identity disorder. The client has issues with developing trust. The client has extremely negative notions about the self. The client is extremely irritable in nature.
The client has issues with developing trust.
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. Management is blaming the client for the accident The client has nightmares about the accident The client says the client is "unable to face that place again" The accident took place 2 weeks ago The client says the client's family describes the client now as "edgy" and "irritable" SUBMIT ANSWER
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 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's family describes the client now as "edgy" and "irritable" The accident took place 2 weeks ago Management is blaming the client for the accident The client says the client is "unable to face that place again"
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 seeing a client who recently received a letter of denial of admission to a college. The client reports having difficulty sleeping and concentrating on work. The nurse recognizes that the significance of not getting into college is influenced by which factor? Select all that apply. The client incorporates religious values daily. The client is Hispanic. The client lives at home with her parents. The client works at a coffee shop. The client is physically active
The client is Hispanic. The client lives at home with her parents. The client incorporates religious values daily.
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 is extremely silent and prefers remaining isolated. The client reports feeling cautious in social settings. The client voluntarily establishes contact with friends and family.
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.
A client suffered a gunshot injury in a robbery and subsequently developed posttraumatic stress disorder (PTSD). What aspect of the client's current condition was confirm that the client is experiencing hyperarousal? The client is easily startled by sudden noises The client is frequently fatigued after mild exertion The client is highly reluctant to describe the details of the robbery The client changes the subject frequently when speaking
The client is easily startled by sudden noises
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 lacks effective coping strategies The client temporarily dissociated with the traumatic event The client is experiencing hyperarousal The client experienced an episode of derealization
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 "free-floating anxiety" and needs to have medication in order to bring it under control. The client is expressing fear about the surgery. The client's fear is the body's physiologic and emotional response to a known danger. The client has "trait anxiety," and this reflects the client's anger toward the client's mother's surgeon. The client has "signal anxiety," which is always the first symptom of anxiety.
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 anxious. The client is hypervigilant. The client is in a dissociated state. The client is depressed.
The client is hypervigilant.
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 to require temporary inpatient treatment The client is likely experiencing depersonalization as a result of PTSD There is a need for constant supervision because of heightened suicide risk The client's perception is a result of hyperarousal and sympathetic nervous stimulation
The client is likely experiencing depersonalization as a result of PTSD
A client with posttraumatic stress disorder (PTSD) is treated with exposure therapy. What change is most likely expected in the client after receiving this therapy? The client may be able to control thoughts and feelings about the event. The client may become more socially active. The client may be able to sleep better. The client may stop having dreams associated with the traumatic event.
The client may be able to control thoughts and feelings about the event.
The nurse is assigned to care for a client with posttraumatic stress disorder (PTSD). Which is the most appropriate reason for the nurse to be nonjudgmental while interacting with the client? The client may lie about the details asked about the self during history taking. The client may have avoidance behavior, which prevents the client from remembering the traumatic event. The client may have negative feelings about the self. The client may not remember anything that happened and is making up stories.
The client may have negative feelings about the self.
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 client may have difficulty hearing. The client may not understand the language. The client may have short-term memory loss.
The client may need to be reoriented.
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 reports being "obsessed" with monitoring the client's own heart rate and blood pressure. The client reports being unable to remember what happened during and immediately after the event. The client reports being unable to drive down the street where the event occurred. The client reports no longer having any hope for the future.
The client reports being unable to remember what happened during and immediately after the event
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 reports being unable to remember what happened during and immediately after the event. The client reports being unable to drive down the street where the event occurred. The client reports being "obsessed" with monitoring the client's own heart rate and blood pressure. The client reports no longer having any hope for the future.
The client reports being unable to remember what happened during and immediately after the event.
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's family members describe the client as irritable and agitated The client states that the client has been neglecting business in recent weeks The client reports crying at unpredictable times The client reports large gaps in memory of the traumatic event
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. The client will express emotions nondestructively. The client will establish a social support system in the community. The client will demonstrate effective ways of dealing with stress.
The client will be physically safe.
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 has unrealistic expectations of his level of emotional functioning The client's emotional numbing is a protective mechanism The client's depersonalization is an ominous sign The client would likely benefit from anxiolytic medications
The client's emotional numbing is a protective mechanism
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 effect of the client's PTSD on the family Assessment for tardive dyskinesia Assessment for extrapyramidal symptoms The client's use of alcohol or other drugs Characteristics of the client's sleep
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
A nurse is counseling a client who was diagnosed with posttraumatic stress disorder (PTSD). During the session, the client states that the client feels worthless and starts crying. The nurse reassures the client that the client is a survivor rather than a victim. What intervention is the nurse using? The nurse is distracting the client. The nurse is promoting the client's self-esteem. The nurse is using grounding techniques. The nurse is using supportive touch.
The nurse is promoting the client's self-esteem.
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 encourage limiting contact with friends and family until the client's mood improves The nurse should avoid touching the client during interactions unless necessary The nurse should encourage the client to use progressive relaxation techniques rather than prescribed medications The nurse should ensure that a colleague is present when the client is assessed
The nurse should avoid touching the client during interactions unless necessary
A client with dissociative disorder is referred for psychotherapy. What would be the main focus of therapy for this client? To combat feelings such as guilt and self-blame To help the client face troublesome thoughts To reassociate with conciousness To have a positive outlook toward life
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? Administration of monoamine oxidase inhibitors (MAOIs) as prescribed Vigilant monitoring for potential indications of self-harm Education to the client about appropriate social interactions Frequent assessment for delusional thinking or hallucinations
Vigilant monitoring for potential indications of self-harm
The nurse is facilitating a wellness group which includes a client who was suspended from work for an angry outburst. The client most likely has the characteristics of which personality type? A C B D
a
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 35 year-old woman who is going through a divorce due to her husband's extra-marital affair a 12 year old girl who was raped by a family friend an 80 year old man who just lost his wife of 45 years a 50 year old man who just lost his job
a 12 year old girl who was raped by a family friend
The nurse is counseling a female client who is the primary caregiver for her older adult mother who requires total care due to stroke. The client reports having difficulty "recovering from the flu." She tells the nurse she has been experiecing flu-like symptoms for over two weeks. The client is most likely experiencing which consequence of chronic stress? decreased hormonal activity overactivity of the immune system a reduction in lymphocyte function lowered levels of serum cortisol
a reduction in lymphocyte function
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 to a support group created for victims of the tragedy. a family meeting where each member will describe the effects of the client's PTSD. a visit with the therapist to the place where the explosion occurred. a critical examination of the ways the client's PTSD has affected the client's life.
a visit with the therapist to the place where the explosion occurred.
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? referring for hospitalization debriefing about the event prescribing of a sleep aid encouraging exercise
debriefing about the event
A client with posttraumatic stress disorder (PTSD) tells the nurse that the client's recent cognitive behavioral therapy has been difficult. The client states that the client's therapist has the client visualize the sights and sounds from the time that the client was assaulted. This client is likely receiving: cognitive processing therapy. exposure therapy. stress inoculation training. cognitive restructuring.
exposure therapy.
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. potassium level 3.5 mmol/L blood pressure 88/56 mm Hg blood glucose 162 mg/dl respiratory rate 12 breaths per minute heart rate 115 beats per minute
heart rate 115 beats per minute blood glucose 162 mg/dl
The nurse provides care to a client who experiences chronic stress. Which physiologic consequence of chronic stress does the nurse include in the client's plan of care? increased risk for illness increased risk for depression increased risk for anxiety increased risk for hostility
increased risk for illness
Which physiologic finding does the nurse anticipate when assessing a client who is experiencing the alarm reaction stage of the general adaptation syndrome (GAS) to stress? increased serum glucose level decreased blood pressure (BP) decreased respiratory rate constricted pupils
increased serum glucose level During the alarm reaction stage of the GAS to stress, the nurse anticipates the client will have increased serum glucose levels due to the stimulation of the sympathetic nervous system. Other anticipated findings include dilated, not constricted, pupils; an increased, not decreased, respiratory rate; and an increased, not decreased, BP
The nurse is seeing a male client who is obese and wants to lose weight. The client discusses why he wants to lose weight, how he recognizes that being obese is unhealthy, and that he plans to remain committed to a healthy lifestyle. The nurse recognizes that the client is engaging in which activity? secondary appraisal primary appraisal coping fight or flight response
primary appraisal In a primary appraisal, a person evaluates the events occurring in his or her life as a threat, harm, or challenge. During primary appraisal of a goal, the person determines whether (1) the goal is relevant, (2) the goal is consistent with his or her values and beliefs, and (3) whether a personal commitment is present. In this case, the client moving through this process as he sets the goal to establish a healthier lifestyle. In a secondary appraisal, the person explains the outcome of events. There may be blame or credit given for the outcome. In this case, the client has not yet experienced the outcome. A "fight or flight" response occurs when the heart rate, blood pressure, and blood sugar increase. Energy is mobilized for survival. This is the response during acute stress. Coping is a deliberate, planned, and psychological effort to manage stressful demands. The coping process may inhibit or override the innate urge to act.
The nurse is working with a client who has the tendency to "tend and befriend." The nurse identifies this is characteristic of: the female response to stress. an aggressive response to stress. a response using denial of emotions. the male response to stress.
the female response to stress.
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: states of catatonia alternating with mania. wide variations in the personality that the client exhibits. hostility and possibly violence. childlike intellectual development and problem-solving skills.
wide variations in the personality that the client exhibits.
