MentalHealth Chapter 13

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

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

The nurse assesses a client's emotional response to a current life crisis. Which question does the nurse ask to determine if the client is experiencing negative emotions?

"Are you experiencing anger or anxiety?"

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."

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 have anyone whom you consider as a close personal contact?"

The nurse is teaching a client about eustress. Which statement made by the client would indicate effective teaching?

"Eustress can occur with happy events such as getting married or having a baby."

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

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

The 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?"

The nurse is assessing a client who lost family and all material possessions in an earthquake. After reviewing the history, the nurse suspects that the client has posttraumatic stress disorder (PTSD). Which statements of the client might lead the nurse to make this interpretation? Select all that apply.

"I am not able to sleep at night." "I prefer being alone, all by myself." "I often have nightmares about the earthquake."

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

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

The nurse is interviewing the client with posttraumatic stress disorder (PTSD) about sleep patterns. Which statement(s) by the client would indicate to the nurse that the client is experiencing hyperarousal? Select all that apply.

"If it's impossible for me to sleep, I sometimes drink until I pass out." "I get extremely angry, and often scream at people for the smallest thing if I don't sleep."

While the nurse is caring for the client with posttraumatic stress disorder (PTSD), the client states, "I don't sleep. Why is that important?" What is the best response by the nurse?

"Improved sleep may help improve your PTSD symptoms."

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 nurse is completing the admission assessment for a client admitted to the inpatient unit for suicidal ideation. The client does not want to answer any more questions, and states, "Everyone is just asking the same questions again and again. I don't have a problem, and I don't need a nurse." What is the nurse's best response?

"What questions have you been asked so far?"

A client is admitted to the psychiatric-mental health unit with a history of childhood abuse and a recent suicide attempt. The client describes feelings of fatigue and is commonly ill. How should the nurse best advise the client?

"You are in a chronic stress state, which has negative health consequences. It's important to take some time for yourself to relax and heal."

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

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

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

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

A nurse finds a client diagnosed with posttraumatic stress disorder (PTSD) curled up in a defensive posture experiencing a flashback. Which intervention(s) will be helpful in eliminating the flashback experience? Select all that apply.

Ask the client to stand up. Have the client focus on the movement of feet and arms.

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

Assess the child for further signs of disinhibited social engagement disorder

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

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

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

Assessing the quantity and quality of the client's sleep

A nurse is performing an assessment interview with a client. The client tells the nurse that their personality type is C. Based on the nurse's interpretation, the nurse would expect which behavior by the client?

Being pleased with the overall pace of the interview

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

A nurse is caring for a client with posttraumatic stress disorder (PTSD). On reassessing the client, the nurse finds that the client shows signs of another psychiatric disorder as well. Signs of which psychiatric disorders would the nurse likely see in this client? Select all that apply.

Depression Anxiety disorder

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

Educate the family about the client's hyperarousal

A client with posttraumatic stress disorder (PTSD) is experiencing hyperarousal and flashbacks. Which is the priority action by the nurse?

Encourage the client to talk about their experience(s) be accepting and nonjudgmental of the client's accounts and perceptions.

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

Enhanced resilience for the participants

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

Exercising regularly, but not close to bedtime

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

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

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

Facilitate the client's participation in a support group

When explaining dissociative disorders to a client, what feature of these disorders would a nurse describe?

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.

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

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?

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 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?

Keep environmental noises to a minimum.

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

Make efforts to demonstrate empathy to the client

A 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?

Negative personal beliefs

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

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

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

Planning activities where the client and the child can bond

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

Posttraumatic stress disorder

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

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

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

Reduced anxiety

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

Teaching the child how to interact appropriately with strangers

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

The child gives adults enthusiastic hugs immediately after meeting them

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

The children have differing levels of resilience

A nurse is assessing a client with dissociative disorder. Which would be the most likely cause of dissociative disorder in the client?

The client has been a victim of rape.

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

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

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

The client is experiencing hyperarousal

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

The client is hypervigilant.

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

The client is likely experiencing depersonalization as a result of PTSD

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

The client is often "staring into space" and has no idea how much time has passed

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 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 have negative feelings about the self.

A nurse is assessing a victim of rape with a diagnosis of posttraumatic stress disorder (PTSD). The client is trying to recall and express the trauma. The nurse finds that, at times, the client is unable to remember certain facts associated with the trauma. What would the nurse interpret from this finding?

The client may have repressed memories.

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

The client may need to be reoriented.

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

The client reports large gaps in memory of the traumatic event

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

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

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 promoting the client's self-esteem.

A nurse is caring for a client with posttraumatic stress disorder (PTSD) who is treated with cognitive-behavioral therapy. Which outcomes achieved by the client will the nurse identify after the four to five days of therapy? Select all that apply.

There will be a decrease in anxiety and fear. Discussion of the traumatic event will be forthcoming.

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

To reassociate with conciousness

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

Vigilant monitoring for potential indications of self-harm

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

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

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

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

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

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

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

debriefing about the event

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

establishing therapeutic rapport with the client.

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:

exposure therapy.

A nurse refers a client with posttraumatic stress disorder (PTSD) to group therapy. Group therapy will likely be more beneficial than individual therapy for this client because group therapy may:

help the client better express feelings.

A female client with post-traumatic stress disorder (PTSD) has just completed a session of eye movement, desensitization, and reprocessing (EMDR) therapy and exposure therapy. The client states that she is exhausted because she has been:

imagining the details of the traumatic event with the therapist.

The nurse is assessing the client who experienced a traumatic event. Which finding(s) would the nurse document as resilience exhibited by the client? Select all that apply.

positive self-concept utilizing coping skills

A client is receiving counseling services to increase positive coping ability while dealing with the loss of a loved one. What would be the initial outcome for the services?

the client feeling content with how the stress was handled

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

wide variations in the personality that the client exhibits.