Ch 13
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? Reassuring the client that recovery will occur Educating the client about basic coping strategies Eliciting the details of the traumatic event Establishing therapeutic rapport with the client
Establishing therapeutic rapport with the client
When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what? Failure to integrate identity, memory, and consciousness Overuse of sedatives like alcohol Total amnesia of the events that caused the disorder Disinhibited social engagement, being overly friendly with strangers
Failure to integrate identity, memory, and consciousness
A client has posttraumatic stress disorder (PTSD) following a disaster that resulted in mass casualties. What question should the nurse prioritize when exploring the physical dimensions of this client's PTSD? Have you been able to integrate physical exercise into your daily routine? How would you describe the quality and quantity of your sleep since the incident? Would you say that you're eating a fairly nutritious diet these days? Have you noticed any significant change to your bowel habits, either constipation or diarrhea?
How would you describe the quality and quantity of your sleep since the incident?
A nurse is caring for a mugging victim who has developed posttraumatic stress disorder (PTSD). The nurse suggests that the client learn techniques of self-defense. How will this intervention be helpful to the client? It may help the client develop a sense of safety. It may help the client express feelings related to the traumatic incident. It may help the client deal with sleep-related issues. It may help prevent flashbacks associated with the traumatic incident.
It may help the client develop a sense of safety.
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 Improved mood Increased energy Decreased nightmares
Reduced anxiety
Eight months ago, a client was in a hotel fire and was the last person to be rescued from the roof. The client watched the client's spouse burn to death from the helicopter. The client continues to have nightmares and is fearful that the client will die in a fire. An appropriate nursing diagnosis for the client is what? Anxiety related to illusions Unrealistic fear of fire related to conversion reaction Ego disintegration related to severe anxiety Sleep pattern disturbance related to recurrent nightmares
Sleep pattern disturbance related to recurrent nightmares
A client with posttraumatic stress disorder (PTSD) is having a flashback experience of a traumatic event. The client asks the nurse if the client can hold the nurse's hand. What should the nurse interpret from this behavior? The client is extremely terrified. The client is dissociating. The client benefits from supportive touch. The client is taking a defensive posture.
The client benefits from supportive touch.
The nurse is assessing a client who was sexually assaulted several months ago and who has subsequently developed posttraumatic stress disorder (PTSD). The nurse observes that the client's nonverbals are closed and the client is reluctant to engage with the nurse. How should the nurse best interpret this client's behavior? The client's PTSD is affecting the client's cognition and information processing The client has likely had a series of negative interactions with health providers The client has likely responded poorly to prior treatments The client's trauma likely has an impact on the client's ability to trust
The client's trauma likely has an impact on the client's ability to trust
A client is admitted to the hospital with posttraumatic stress disorder (PTSD). When approaching the client for the first time, the nurse speaks softly and gently, in a nonthreatening manner. What is the most appropriate reason for this behavior of the nurse? To prevent the risk of triggering fears in the client To calm the client and prevent an outburst of anger To help the client sleep better To learn about the client's experience
To prevent the risk of triggering fears in the client
Flashbacks and feelings of unreality are associated with what? Panic disorder Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Agoraphobia
Posttraumatic stress disorder (PTSD)
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. Encourage the client to delay discussing the stressful event until coping can occur. Encourage the client to utilize distraction when remembered experiences come to their mind. Guide the client to let go of the events of the traumatic event.
Promote discussion of the client's thoughts and feelings about the stressful event.
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? I thought I could do this on my own, but I can see now why the doctor suggested medication. 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. Sometimes I feel like I can't even cope unless I've had a few drinks to calm my nerves.
Sometimes I feel like I can't even cope unless I've had a few drinks to calm my nerves.
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 frequently fatigued after mild exertion The client is easily startled by sudden noises 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
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 would likely benefit from anxiolytic medications The client's depersonalization is an ominous sign
The client's emotional numbing is a protective mechanism
The nurse is seeing a client who reports recent difficulty with sleep and decreased appetite. The client reports having pressure from work due to an upcoming deadline and moving to a different house at the same time. What is the client most likely experiencing? type A personality diathesis chronic stress acute stress
acute stress
A client with posttraumatic stress disorder (PTSD) has destructive thoughts and has potentiality for self-harm or suicide. What instruction should the nurse give to the client to ensure the client's safety? "Go to the terrace for some fresh air when you have disturbing thoughts." "Come and sit with me when you are fearful or have disturbing thoughts." "Eat candy when you have disturbing thoughts." "Try to sleep when you have disturbing thoughts."
"Come and sit with me when you are fearful or have disturbing thoughts."
A nurse is caring for a client who is experiencing a flashback of a violent event and is curled up in bed. What should the nurse do? Ask the client to lie down properly. Touch the client's arm to sympathize with the client. Use supportive touch after asking for the client's permission. Leave the client alone to help the client sort out the client's thoughts.
Use supportive touch after asking for the client's permission.
Which statement made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms? "It's like I'm having flashbacks every time I fall asleep." "Loud noises always make me a little jittery now." "I describe my feelings like I'm having an out-of-body experience." "I feel guilty that I survived the attack and my friend didn't."
"I describe my feelings like I'm having an out-of-body experience."
The nurse is working with a client who has been experiencing nightmares, hyperarousal and negative thoughts following a bomb threat at the client's workplace. The nurse's colleague states, "It turned out to be just a threat, not a bombing, so technically she can't have posttraumatic stress disorder (PTSD)." What is the nurse's best response? "PTSD is a real possibility, even though the bombing never actually took place." "Yes, but if the bombing had occurred, I'm sure she'd be diagnosed with PTSD." "Right, but the client's symptoms certainly constitute a diagnosis of adjustment disorder." "If the client responds to prescribed medications, then that will certainly confirm the diagnosis."
"PTSD is a real possibility, even though the bombing never actually took place."
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 affect your body's immune system, which can increase the symptoms of your disease." "Stress can be felt as painful, which can harm the person with a chronic disease." "Stress can not cause heart 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."
The nurse is working with a 17-year-old client with a complex and dysfunctional family background. What aspect of this client's history should the nurse identify as the most significant risk factor for posttraumatic stress disorder (PTSD)? The client moved more than 12 times before turning 10 years old The client's mother has a long history of alcohol abuse The client was placed in foster care for the first 4 months of life The client was sexually abused by the mother's boyfriend at a young age
The client was sexually abused by the mother's boyfriend at a young age
A nurse is caring for a client who has been brought to the emergency department after witnessing the death of a close family member during a motor vehicle accident. Which signs and symptoms should the nurse anticipate observing during the initial assessment? pulse 60 oxygen saturation of 95% respiratory rate of 12 breaths per minute bp 170/92
BP 170/92
Which client should the nurse assess most closely for signs and symptoms of posttraumatic stress disorder (PTSD)? A client who has recently undergone radiotherapy and chemotherapy for cancer 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 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
A nurse is caring for a client with posttraumatic stress disorder (PTSD). The client does not express emotions and is not willing to talk to anybody. What nursing action would be most appropriate to help the client express the client's feelings? Ask the client to talk to a family member. Ask the client to retell the experience without crying. Refer the client for electroconvulsive therapy. Ask the client to write down all feelings and emotions on a piece of paper.
Ask the client to write down all feelings and emotions on a piece of paper.
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 Developing therapeutic rapport with the client and family Identifying the client's coping ability and functional status Assessing the client's current drug regimen and allergy status
Assessing the client's risk for self-harm and ensuring safety
A combat veteran with posttraumatic stress disorder has been admitted to the psychiatric unit after consuming a large number of antidepressants and drinking half a quart of whiskey 2 days earlier. What aspect of care should the nurse prioritize? Affirming the client's self-worth and self-concept Mobilizing the client's social support network Developing a therapeutic relationship with the client Monitoring the client for suicidal ideation
Monitoring the client for suicidal ideation
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 example would the nurse most likely include? Select all that apply. Personal assault by a family member Military combat mission where there were casualties Surviving an EF 4 tornado Urinary incontinence due to a prolapsed bladder Falling off a playground swing
Personal assault by a family member Military combat mission where there were casualties Surviving an EF 4 tornado
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's differing responses are genetically determined The children have differing levels of resilience The child who is more traumatized is developmentally delayed The child who is less traumatized is developmentally delayed
The children have differing levels of resilience
A police officer was diagnosed with posttraumatic stress disorder after attending to a violent crime scene. What aspect of the client's current health status would most likely warrant inpatient treatment? The client alluded to "ending this misery" in a conversation with a colleague The client's care provider has increased the dose of paroxetine twice in 2 months The client has twice attempted a return to work, without success The client admits that the client often lashes out verbally at the client's spouse and children
The client alluded to "ending this misery" in a conversation with a colleague
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 stop having dreams associated with the traumatic event. The client may become more socially active. The client may be able to control thoughts and feelings about the event. The client may be able to sleep better.
The client may be able to control thoughts and feelings about the event.
A nurse is assessing a young client who has recently witnessed a murder. Despite directly witnessing the crime, the client has been unable to provide proper information about the event to the police. The client tells the nurse that the client does not remember anything related to the crime scene. What is the most likely cause for the inability to remember the events related to the scene? The client may be lying about the inability to remember the scene. The client may have been under the influence of drugs. The client may have Alzheimer's disease. The client may have dissociative amnesia.
The client may have dissociative amnesia.
During an interview, a rape victim says, "I don't think of anything else but the incident. I think I have had enough problems in life and there is no purpose for my life, either. Now all I need is to go back to the Lord Almighty." The nurse advises the client to be admitted in the psychiatric facility. What would be the reason for the nurse to ask the client to be admitted? The client may be unable to cope with the stress. The client may be extremely depressed. The client may have negative feelings about the self. The client may have suicidal ideation.
The client may have suicidal ideation.
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 have difficulty hearing. The client may have short-term memory loss. The client may need to be reoriented. The client may not understand the language.
The client may need to be reoriented.
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 ensure that a colleague is present when the client is assessed 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 avoid touching the client during interactions unless necessary
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. gently encouraging the client to talk about the incident eliciting the objective facts about the incident. reassuring the client that the client is having an expected response to such an incident.
establishing therapeutic rapport with the client.
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? "It's more likely that the client is experiencing anxiety, which will likely decrease with time." "Actually, she won't meet the diagnostic criteria for PTSD until 3 months after the attack." "Acute stress disorder is a possibility, which might develop into PTSD." "If the client doesn't receive treatment right away, the client might not recover from the PTSD."
"Acute stress disorder is a possibility, which might develop into PTSD."
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? "Looking after you is our work. We are strong enough to tolerate your behavior." "Expressing your feelings will de-stress you and we want you to get well soon." "Calm down and avoid talking, as this will make you angry." "You need to control your anger. Your outbursts will not be tolerated."
"Expressing your feelings will de-stress you and we want you to get well soon."
Which individual is most likely to be diagnosed with posttraumatic stress disorder (PTSD)? A teenage boy who has begun to be the object of bullying inside and outside the classroom A 12-year-old girl who has recently moved cross-country and desperately misses her old friend A middle-aged woman with a history of anxiety who suffered a random physical assault An adult male client who has been admitted to the hospital three times for complications of surgery
A middle-aged woman with a history of anxiety who suffered a random physical assault
A client informs the nurse that while on vacation at a theme park, the sound of fireworks triggered an intense reminder of a house fire experienced as a child. The client describes experiencing the smells from the fire, choking sensations, burning eyes and images of the flames destroying the insides of his home. Which symptom is experienced by the client? Hallucination Dissociation Derealization Flashback
Flashback
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. 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.
Keep environmental noises to a minimum.
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. The client has been involved in illicit drug use. The client has had a head injury in the past. The client has been taking anxiolytic drugs.
The client has been a victim of rape.
A client with posttraumatic stress disorder (PTSD) is admitted to a psychiatric unit. Which is the most appropriate reason for the head nurse to appoint one nurse to provide complete care for the client? The client does not need much care. The client would be able to express feelings better. The client has difficulty with familiarizing and trusting people. The client would be more responsive to therapy.
The client has difficulty with familiarizing and trusting people.
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 extremely negative notions about the self. The client has issues with developing trust. The client is extremely irritable in nature.
The client has issues with developing trust.
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 fear about the surgery The client's fear is the body's physiologic and emotional response to a known danger. The client has "signal anxiety," which is always the first symptom of anxiety. The client has "trait anxiety," and this reflects the client's anger toward the client's mother's surgeon. 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.
What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation? The client experiences awakenings during the night and is unable to fall asleep again The client states that usual coping mechanisms are ineffective The client states that the client's mood is "alright" when appearing to be in some distress The client is often "staring into space" and has no idea how much time has passed
The client is often "staring into space" and has no idea how much time has passed
While doing the routine basic physical assessment of a client with posttraumatic stress disorder (PTSD), the nurse finds that the client appears totally numb with a blank stare. What does this sign most likely indicate? The client may be under the influence of illicit drugs. The client may have dissociative symptoms. The client may have improved with psychotherapy. The client may have lost consciousness.
The client may have dissociative symptoms.
The nurse is dialoguing with a client who has been referred after witnessing a workplace accident several weeks ago that resulted in a coworker's death. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)? The client had to take several sick days in the days after the event. The client's work performance has suffered after the event. The client avoided the coworker's family in the days after the event. The client states that the client is often "awake for hours and hours each night."
The client states that the client is often "awake for hours and hours each night."
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 establish a social support system in the community. The client will express emotions nondestructively. The client will be physically safe. The client will demonstrate effective ways of dealing with stress.
The client will be physically safe.
A nurse is working in a mental health clinic. Which client statement should the nurse recognize as describing a type A personality? "I just agree with whatever my co-workers say so nobody will be upset with me." "I'm a very relaxed person. Whatever everybody else wants is fine with me." "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 work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself."
The nurse is preparing to give a group therapy session for clients with posttraumatic stress disorder (PTSD). Which clients are most likely to be included in the group therapy session? Select all that apply. A client who has witnessed a murder. A client who has watched the news about a major flood in another country on television. A client who is a victim of a car accident. A client who has read disturbing news in the newspaper. A client who has lost the client's spouse and children in a natural disaster.
A client who has witnessed a murder. A client who is a victim of a car accident. A client who has lost the client's spouse and children in a natural disaster.
