Chapter 19: Trauma & Stressor-Related Disorders

Which of the following is the most commonly used treatment for clients with adjustment disorder (AD) and its appropriate rationale? 1. Psychotherapy; to examine the stressor and confront unresolved issues 2. Selective serotonin reuptake inhibitors; to stabilize mood and resolve symptoms 3. Eye movement desensitization therapy; to reprocess traumatic events 4. Antianxiety agents; a first-line treatment to address symptoms of anxiety

Answer: 1 Rationale: 1 Psychotherapy is the most common treatment used for AD. Individual psychotherapy allows the client to examine the stressor that is causing the problem, possibly assign personal meaning to the stressor, and confront unresolved issues that may be exacerbating this crisis. 2 AD is not commonly treated with medications because it masks the real problem and psychoactive drugs can be addictive. Selective serotonin reuptake inhibitors are considered the first-line pharmacological choice for posttraumatic stress disorder, not AD. 3 Eye movement desensitization and reprocessing therapy is not used to treat adjustment disorders, but it is used for posttraumatic stress disorder to reprocess traumatic events. 4 Antianxiety and antidepressant medications may be prescribed as adjuncts to psychotherapy but should not be given as the first line of treatment for AD.

The client diagnosed with posttraumatic stress disorder (PTSD) has a nursing diagnosis of posttrauma syndrome R/T surviving a workplace shooting. Which nursing intervention would the nurse add to this client's plan of care? 1. Monitor for substance use 2. Alternate staff members 3. Use a firm approach 4. Offer social skill training

Answer: 1 Rationale: 1 The nurse must monitor for substance use, as this can be a maladaptive form of coping clients with PTSD employ. 2 The nurse should assign the same staff as often as possible to facilitate a trusting relationship, as post-trauma clients may be suspicious of others. 3 The nurse should use a nonthreatening, matter-of-fact, but friendly approach, not a firm approach, for clients with PTSD. 4 In clients with PTSD, the issue is not social skill training but establishing adaptive coping strategies and finding their "place" in the world following the trauma.

Which information will help the nurse differentiate the diagnosis of posttraumatic stress disorder (PTSD) from the diagnosis of adjustment disorder (AD)? 1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events. 2. AD is more common in women, whereas PTSD is more common in men. 3. AD can occur from severe motor vehicle accidents, while PTSD can occur from the birth of a stillborn. 4. PTSD occurs more often when compared to AD.

Answer: 1 Rationale: 1 PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events or "less extreme" events, such as being a victim of bullying or being incarcerated. 2 Both PTSD and AD occur more often in women. 3 An example of a situation causing PTSD is a severe motor vehicle accident, whereas an example of a situation causing AD is birth of a stillborn. 4 AD is more common than PTSD. Less than 10% of patients develop PTSD, while research has indicated that AD disorders are quite common.

Which statement indicates a nurse has a correct understanding about how eye movement desensitization and reprocessing (EMDR) achieves its therapeutic effect? 1. "The exact biological mechanism is unknown." 2. "It causes an increase in imagery vividness." 3. "This therapy decreases memory access." 4. "EMDR disrupts the fear associated with trauma."

Answer: 1 Rationale: 1 This statement indicates the nurse has a correct understanding. The exact biological mechanisms by which EMDR achieves it therapeutic effects are unknown. However, some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory access. 2 This statement indicates an incorrect understanding. Some studies have indicated that EMDR causes a decrease in imagery vividness, not an increase. 3 This statement indicates the nurse does not have a correct understanding. EMDR has shown to increase memory access, not decrease it. 4 This statement is incorrect and indicates an incorrect understanding. EMDR does not achieve its effect by disrupting the fear associated with trauma. Ketamine, an anesthetic agent, produces this effect.

The nurse is admitting a client who has been diagnosed with posttraumatic stress disorder (PTSD). Which symptoms might the nurse observe upon assessment? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month

Answer: 1, 2, 3, 4 Rationale: 1 Characteristic symptoms of PTSD include guilt feelings, especially survivor guilt, that can lead to social isolation. 2 Characteristic symptoms of PTSD include aggressive behaviors and impaired occupational functioning. 3 Characteristic symptoms of PTSD include relationship problems with feelings of detachment or estrangement from others. 4 Characteristic symptoms of PTSD include high levels of anxiety with hypervigilance and exaggerated startle response. 5 This is not a characteristic symptom of PTSD. The full-symptom picture must present for more than 1 month and cause significant interference with social, occupational, and other areas of functioning.

The client diagnosed with an adjustment disorder says, "Tell me about medications that will cure this problem." Which responses by the nurse are appropriate? (Select all that apply.) 1. "Medications can interfere with your ability to find a more permanent solution." 2. "Medications may mask the real problem at the root of this diagnosis." 3. "Adjustment disorders are not commonly treated with medications." 4. "Psychoactive drugs carry the potential for physiological and psychological dependence." 5. "Psychoactive drugs will be prescribed only if your problems persist for more than three months."

Answer: 1, 2, 3, 4, Rationale: 1 Adjustment disorders are not commonly treated with medications because of interfering with finding a permanent solution. 2 Adjustment disorders are not commonly treated with medications because of masking the real problem. 3 Adjustment disorder is not commonly treated with medication. 4 Adjustment disorders are not commonly treated with medications because of the potential for physiological and psychological addiction. 5 Adjustment disorder is not commonly treated with medication regardless of symptoms lasting more than 3 months.

Based upon the research with Vietnam veterans, which factors are the best predictors of posttraumatic stress disorder (PTSD)? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology

Answer: 1, 3 Rationale: 1 In research with Vietnam veterans, it was shown that one of the best predictors of PTSD was the severity of the stressor. 2 Ego strength is not one of the best predictors of PTSD in Vietnam veterans research studies. 3 In research with Vietnam veterans, it was shown that one of the best predictors of PTSD was the degree of psychosocial isolation in the recovery environment. 4 Attitudes of society is not one of the best predictors of PTSD in Vietnam veterans research studies. 5 In research with Vietnam veterans, preexisting psychopathology is not one of the best predictors of PTSD.

The client has a nursing diagnosis of complicated grieving related to the death of multiple family members from a tornado. Which action should the nurse take first? 1. Encourage the journaling of feelings. 2. Assess for the stage of grief in which the client is fixed. 3. Provide community resources to address the client's concerns. 4. Suggest attending a grief therapy group.

Answer: 2 Rationale: 1 While encouraging the client to journal feelings is appropriate, it is not the first action. 2 Prior to implementing all other nursing interventions presented, the nurse must assess the stage of grief in which the client is fixed. Appropriate nursing interventions are always based on accurate assessments. 3 While providing community resources is appropriate, it is not the first action the nurse should take. 4 While grief therapy is important, it is not the first intervention. Grief therapy will come later in the healing process.

The client receiving eye movement desensitization and reprocessing (EMDR) therapy says, "After only three sessions, I am feeling great. Now I can stop and get on with my life." Which response by the nurse is most appropriate? 1. "I am thrilled that you have responded so rapidly to EMDR." 2. "To achieve lasting results, all eight phases of EMDR must be completed." 3. "If I were you, I would complete the EMDR and comply with the health-care provider's orders." 4. "How do you feel about continuing the therapy?"

Answer: 2 Rationale: 1 This statement is false praise because it does not educate the client about completing all phases of EMDR. 2 This statement is most appropriate. Clients often feel relief quite rapidly with EMDR. However, to achieve lasting results, it is important that each of the eight phases be completed. The nurse's most appropriate response should be to give information to correct the client's misconceptions about the therapy. 3 In this inappropriate response, the nurse is subjectively giving advice rather than providing objective information. 4 This statement is inappropriate because the client has already stated feelings about continuing EMDR.

The client has been extremely anxious ever since relocating to another state because of a job transfer. When assessing for the diagnosis of adjustment disorder (AD), within what time frame should the nurse expect the client to exhibit symptoms? 1. Within 1 year of the move 2. Within 3 months of the move 3. Within 6 months of the move 4. Within 9 months of the move

Answer: 2 Rationale: 1 Exhibiting symptoms within 1 year does not meet the DSM-5 diagnostic criteria for adjustment disorders. This is too long of a time period. 2 According to the DSM-5 diagnostic criteria for adjustment disorders, the development of emotional or behavioral symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor. 3 Exhibiting symptoms within 6 months does not meet the DSM-5 diagnostic criteria for adjustment disorders. This is too long of a time period. According to the DSM-5, 6 months or less is the amount of time the response has persisted, not when it will occur. 4 Exhibiting symptoms within 9 months does not meet the DSM-5 diagnostic criteria for adjustment disorders. This is too long of a time period.

After a teaching session about grief, a client says to the nurse, "I seem to be stuck in the bargaining stage of grieving over the loss of my daughter." In which phase of the nursing process would this occur, and how would the nurse interpret this statement? 1. Assessment phase; nursing actions have been successful in achieving accurate data. 2. Evaluation phase; nursing actions have been successful in achieving the objectives of care. 3. Implementation phase; nursing actions have been successful in achieving the objectives of care. 4. Diagnosis phase; nursing actions have been successful in achieving accurate data.

Answer: 2 Rationale: 1 This statement does not reflect the assessment phase because it occurs after a teaching session. 2 The statement occurs in the evaluation phase. In the evaluation phase of the nursing process, reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. The implementation of client teaching has enabled the client to verbalize an understanding of the grief process and his or her position in the process. Therefore, the nurse's actions can be evaluated as successful. Without the evaluation phase, it would be difficult for the nurse to determine if actions have been successful. 3 This statement does not reflect the implementation phase. The implementation phase in this question occurs when the nurse teaches the client. Implementation focuses on implementing actions/interventions. 4 This statement does not reflect the diagnosis phase. The diagnosis phase occurs when the nurse develops a nursing diagnosis based upon assessment data.

The nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates teaching has been effective? 1. "How clients perceive events and view the world affects their response to trauma." 2. "Psychic numbing in PTSD is a result of negative reinforcement." 3. "The individual becomes addicted to the trauma owing to an endogenous opioid response." 4. "Believing that the world is meaningful and controllable can protect an individual from PTSD."

Answer: 2 Rationale: 1 This statement indicates that further education is necessary. This statement describes cognitive theory, not learning theory. 2 This statement indicates effective teaching. Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. Psychic numbing decreases or protects an individual from emotional pain and, therefore, the learned response is the repetition of this behavior. 3 This statement is incorrect, indicating that further teaching is needed. This statement focuses on biological responses, not learning theory. 4 This statement indicates that teaching has not been effective. This statement describes cognitive theory, not learning theory.

The client diagnosed with posttraumatic stress disorder (PTSD) asks, "Why did my health-care provider prescribe an antidepressant rather than an antianxiety drug for me?" Which explanations should the nurse make? (Select all that apply.) 1. "I'm not sure, because antianxiety drugs have been approved by the FDA for PTSD." 2. "Antidepressants are now considered first-line treatment choice for PTSD." 3. "Many people experience side effects to antianxiety drugs." 4. "Because of their addictive properties, antianxiety drugs are less desirable." 5. "That is strange because antipsychotics have provided the best results for treatment of PTSD."

Answer: 2, 4, 5 Rationale: 1 Paroxetine and sertraline (antidepressant drugs), not antianxiety drugs, have been approved by the FDA for the treatment of PTSD. 2 Antidepressants, specifically certain selective serotonin reuptake inhibitors, are now considered the first-line treatment of choice for PTSD. 3 While side effects can occur with the use of antianxiety drugs, this is an inaccurate explanation. Based upon a meta-analysis finding, benzodiazepines, antianxiety agents, worsen clients' PTSD symptoms and should not be used. 4 Addictive properties of antianxiety agents make them less desirable than other medications used in the treatment of PTSD. 5 There is little positive evidence concerning the use of antipsychotics in the treatment of PTSD. These drugs are only used for short-term control of severe aggression and agitation.

Parents ask the nurse why their daughter was diagnosed with posttraumatic stress disorder (PTSD) and others survivors of the terrorist attack were not. Which information should the nurse offer? (Select all that apply.) 1. An individual's stated religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The duration of how long the trauma lasted can affect the individual's response.

Answer: 2,3,4,5 Rationale: 1 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are not related to a client's stated religious affiliation. While spiritual support can enhance successful adaptation, an individual's specific religious affiliation should have no bearing or influence on the development of PTSD. 2 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the individual, such as outcomes of previous experiences with stress or trauma. 3 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the recovery environment, like the cohesiveness and protectiveness of family and friends. 4 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the traumatic experience, such as amount of control over recurrence. 5 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the traumatic experience, like duration and severity of the stressor.

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client's symptom? 1. Anxiety 2. Altered thought processes 3. Complicated grieving 4. Altered sensory perception

Answer: 3 Rationale: 1 Although the client may also experience anxiety, the symptom presented in the question is extreme guilt. 2 There is no evidence presented in the question to indicate altered thought processes. 3 The client's survivor guilt is disrupting the normal process of grieving, indicating complicated grieving as the nursing diagnosis. 4 There is no evidence presented in the question to indicate altered sensory perception.

The nurse is caring for a client diagnosed with posttraumatic stress disorder (PTSD). Which realistic goal should be included in this client's plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require medication to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.

Answer: 3 Rationale: 1 Having no flashbacks by discharge is an unrealistic goal. A realistic goal is that the flashbacks have decreased. 2 Experiencing a full range of emotions by discharge is an unrealistic and unhealthy goal. 3 Obtaining adequate sleep without medication by discharge is a goal that should be included in the client's plan of care. 4 Clients are encouraged, not discouraged, to discuss the traumatic event. The goal is for the client to voluntarily discuss the traumatic event.

8. The nurse is describing the Transactional Model of Stress and Adaptation. When using this model, which factor would the nurse categorize as intrapersonal? 1. Occupational opportunities 2. Economic conditions 3. Degree of flexibility 4. Availability of social supports

Answer: 3 Rationale: 1 Occupational opportunities are categorized as situational, not intrapersonal. 2 Economic conditions would not be categorized as intrapersonal. Economic conditions are classified as situational factors. 3 Degree of flexibility is an intrapersonal factor in this model. Intrapersonal factors that might influence an individual's ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence. 4 Availability of social supports would be categorized as situational, not intrapersonal.

Which action would the nurse take to provide trauma-informed care to a homeless client who is combative? 1. Place the client in seclusion 2. Apply soft wrist restraints 3. Allow the client some control 4. Encourage dependent behavior

Answer: 3 Rationale: 1 Placing the client in seclusion is the last resort and is avoided because it can retraumatize the client. This action is not reflective of trauma-informed care. 2 Applying restraints is not reflective of trauma-informed care. Applying restraints can retraumatize the client with a history of trauma. 3 Empowering the trauma survivor to guide and direct his or her recovery plan by providing input is reflective of trauma-informed care. 4 Encouraging dependent behavior is not reflective of trauma-informed care. The goal is to rebuild a sense of hope, control, and empowerment, not dependency.

The client is receiving eye movement desensitization and reprocessing (EMDR) treatments. The nurse is most likely caring for which client? 1. One with schizophrenia 2. One with borderline personality disorder 3. One with manic episodes 4. One with posttraumatic stress disorder

Answer: 4 Rationale: 1 EMDR is not used for schizophrenia. 2 EMDR has not been approved for use with borderline personality disorders. 3 While EMDR has been used for depression, it has not been empirically validated for manic episodes. 4 EMDR is used for posttraumatic stress disorder (PTSD). It has been used for depression, adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic disorder, but it has only been empirically validated for PTSD.

A 22-year-old client and a 62-year-old client were involved in motor vehicle accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which client would be predisposed to the diagnosis of adjustment disorder? 1. The 62-year-old, because of memory deficits 2. The 62-year-old, because of uncomplicated bereavement 3. The 22-year-old, because of decreased cognitive processing 4. The 22-year-old, because of lack of developmental maturity

Answer: 4 Rationale: By comparison in psychosocial theory, the 22-year-old does not have the developmental maturity, life experiences, and coping strategies that the 62-year-old might possess.

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)? 1. Anxiety, feelings of hopelessness, and worry 2. Truancy, vandalism, and fighting 3. Nervousness, worry, and jitteriness 4. Depressed mood, tearfulness, and hopelessness

Answer: 4 Rationale: 1 This clinical presentation is associated with adjustment disorder with mixed anxiety and depressed mood, which is not the most commonly diagnosed adjustment disorder. 2 Truancy, vandalism, and fighting are associated with adjustment disorder with disturbance of conduct, which is not the most commonly diagnosed adjustment disorder. 3 Nervousness, worry, and jitteriness are associated with adjustment disorder with anxiety, which is not the most commonly diagnosed adjustment disorder. 4 AD with depressed mood is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depression. The symptoms—such as depressed mood, tearfulness, and feelings of hopelessness—exceed what is an expected or normative response to an identified stressor.

The nurse is caring for a client with a diagnosis of adjustment disorder unspecified from a divorce after over 30 years of marriage. Which signs and symptoms would the nurse observe? 1. Re-experiences spouse asking for a divorce, is hyperalert, and has nightmares 2. Has anxiety, begins to shoplift, and exhibits reckless driving 3. Is belligerent, violates others' rights, and defaults on legal responsibilities 4. Reports many physical ailments, refuses to socialize, and has unproductive work performance

Answer: 4 Rationale: 1 Re-experiencing the trauma, being hyperalert, and having nightmares are signs and symptoms of posttraumatic stress disorder, not adjustment disorder unspecified. 2 Anxiety, shoplifting, and reckless driving are signs and symptoms of adjustment disorder with mixed disturbance of emotions and conduct, not adjustment disorder unspecified. 3 The client who is belligerent, violates others' rights, and defaults on legal responsibilities is not showing symptoms of an adjustment disorder unspecified but is showing signs and symptoms of adjustment disorder with disturbance of conduct. 4 The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, withdrawal from relationships, or impaired work or academic performance, without significant disturbance in emotions or conduct.

The nurse is teaching a client about the eight-phase process of eye movement desensitization and reprocessing (EMDR). In which order should the nurse list the phases, starting with the early phases and ending with the last (1-4)? (Enter the number of the phases in the proper sequence, using comma and space format, such as 1, 2, 3, 4) 1. Installation 2. Body scan 3. Reevaluation 4. Desensitization

Answer: 4, 1, 2, 3 Rationale: EMDR is an integrative psychotherapy approach with a theoretical model that emphasizes the brain's information processing system and memories of disturbing experiences as the basis of pathology. EMDR has been shown to be an effective therapy for PTSD and other trauma-related disorders. The phases are described as Phase 1: History and treatment planning - a thorough history is taken and treatment plan is developed. Phase 2: Preparation - client learns certain self-care techniques, like relaxation techniques Phase 3: Assessment - client specifies a scene or picture from the target event; negative self-belief and positive self-statement developed; client uses 2 scales: Validity of Cognition (VOC) and Subjective Units of Disturbance (SUD) Phase 4: Desensitization - client gives attention to the negative beliefs and disturbing emotions while focusing on the back-and-forth motion of the therapist's finger; SUD scale is used Phase 5: Installation - client gives attention to the positive belief to replace the negative belief; VOC scale is used Phase 6: Body scan - The client must be able to focus on the traumatic event without experiencing bodily tension Phase 7: Closure - client leaves feeling better than he or she felt at the beginning Phase 8: Reevaluation - The therapist determines whether positive changes have been maintained and identifies any new target areas at the beginning of each new therapy session The sequence for the question is as follows: 1. Desensitization 2. Installation 3. Body scan 4. Reevaluation

The nurse is teaching about trauma- and stressor-related disorders. Which statement by one of the staff members indicates that follow-up instruction is needed? 1. "The trauma that women experience is more likely to be sexual assault and child sexual abuse." 2. "The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury." 3. "After exposure to a traumatic event, less than 10 percent of victims develop posttraumatic stress disorder (PTSD)." 4. "Research shows that PTSD is more common in men than in women."

Answer:4 Rationale: 1 This statement indicates that teaching has been effective and no further instruction is needed. 2 This statement is correct, indicating that no further teaching is needed. 3 This statement is accurate, indicating the teaching has been effective. 4 This statement indicates a need for further instruction. Research shows that PTSD is more common in women than in men.

An extremely distressing experience that causes severe emotional shock and may have long-lasting psychological effects is called ____________________.

trauma