Mental Health Chapter 13

A client with posttraumatic stress disorder (PTSD) tells the nurse that he often feels like he has left his body and is looking at things from a distance. The nurse interprets this as:

Dissociation

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 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?

Monitoring the client for suicidal ideation

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

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 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.

The nurse assesses a 6-year-old child for posttraumatic stress disorder (PTSD). The caregiver explains that the child witnessed the mother being stabbed by a neighbor. Which is a behavior consistent with the child's diagnosis?

A two-month history of angry outbursts with minor provocation

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 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

Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?

Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse.

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.

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

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?

Dissociative identity disorder

A nurse in the emergency department (ED) is aware that seven people were involved in a construction accident and one person was killed. Which is a priority health promotion strategy for the survivors?

Enhance resilience

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

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

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?

How would you describe the quality and quantity of your sleep since the incident?

An adult male 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. He was calm and apologetic when he presented to the triage nurse. Which is a priority nursing intervention?

Identify risks for self-harm and aggression

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

The nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?

Sleep assessment

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

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

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 has difficulty with familiarizing and trusting people.

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 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 says the client's family describes the client now as "edgy" and "irritable" The client says the client is "unable to face that place again" The client has nightmares about the accident

A nurse working in a psychiatric unit is counseling a rape survivor. How can the nurse use cognitive processing therapy for the client?

Use structured sessions to focus on examining beliefs that interfere with daily life.

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

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

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."

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 a journal or a log to write down your feelings."

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

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

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 issues with developing trust.

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

To reassociate with conciousness

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.

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 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.

Having negative beliefs about oneself Inability to remember important aspects of the traumatic event Getting angry with little or no provocation

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 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.

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

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 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's emotional numbing is a protective mechanism

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 trauma likely has an impact on the client's ability to trust

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 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 avoid touching the client during interactions unless necessary

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 am fine, I am going to move on."

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 always seems so irritated now, which isn't like my spouse."

Which clients would likely require inpatient treatment? Select all that apply.

* A client with posttraumatic stress disorder who is overwhelmed by flashbacks * A client with posttraumatic stress disorder who has suicidal thoughts

A client with PTSD is brought to the nurse in a primary care setting with lower back pain after falling from a ladder. The client became aggressive with their partner before agreeing to come to the setting. The nurse smells alcohol on the person's breath and the client does not make eye contact or expand openly to assessment questions. Which are priority nursing assessments? Select all that apply.

* Risk for self-injury * Risk for aggression * Risk for substance abuse

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 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

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.

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

The nurse is caring for a client who is a rape victim. The client has been undergoing psychotherapy for the stress the client is experiencing as a result of this incident. The client has started making accusations against family members of abusing the client. Family members insist the accusations are groundless. What may the client be experiencing?

False memory syndrome

A nurse is assessing risk for trauma and stress-related disorders for a child. Which areas are important for the nurse to ask about? Select all that apply.

Incarceration of a parent Childhood physical abuse Unexpected death of a family member Childhood exposure to mother experiencing violence

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 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 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 took place several months ago, and the client's anxiety has been continuous.

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.

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.

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

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 Set small, specific, achievable goals Have a healthy, balanced diet

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 derealization as a result of PTSD

The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should:

try to identify any strengths or skills that can be applied during recovery.

A nurse is working in a mental health clinic. Which client statement should the nurse recognize as describing a type A personality?

"I work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself."

A psychiatric-mental health nurse is conducting a program for family members of clients diagnosed with posttraumatic stress disorder. When describing the concept of resilience, which information would the nurse most likely include? Select all that apply.

The stronger the resilience, the less likely the person will develop maladaptive behaviors. As positive self-concept increases, resilience also increases over time.

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

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