Post Traumatic Stress Disorder/Syndrome

The nurse has developed a plan of care and is determining which nursing interventions take priority. Rank the nursing actions in order of priority, starting with the highest priority.

1. The nurse will assess physiological needs.​ 2. The nurse will assess psychological needs.​ 3. The nurse will administer prescribed medications using the rights of medication administration. ​ 4. The nurse will help the client determine two coping mechanisms to reduce anxiety-related symptoms.​ 5. The nurse will schedule the next psychotherapy session prior to discharge.​

A nursing student presents to the psychiatric mental health unit to begin their clinical shift. Their assigned client experienced the death of their child at home six months ago. Which statement made by the student needs follow-up from their clinical instructor? A. "My client continues to be upset from their child dying. It's been six months and they should be able to cope with it by now." B. "My client has a history of depression, so this traumatic experience may make it more difficult to cope with." C. "My client is still struggling with their child dying from a sudden, unexpected death at home." D. "My client told me that her in-laws continue to blame her for the death of their grandchild."

A. "My client continues to be upset from their child dying. It's been six months and they should be able to cope with it by now."

The nurse is teaching a client about psychotherapy options to help with their post-traumatic stress disorder (PTSD). Which options could benefit a client with PTSD? Select all that apply. A. Eye movement desensitization and reprocessing (EDMR) B. Antidepressants C. Prolonged exposure (PE) D. Cognitive processing therapy (CPT) E. Traumatic exposure

A. Eye movement desensitization and reprocessing (EDMR) C. Prolonged Exposure (PE) D. Cognitive Processing Therapy (CPT)

A 45-year-old male client has post-traumatic stress disorder (PTSD), related to military combat. Which action best indicates the client is coping with the diagnosis? A. Sleeps through the night uninterrupted B. Drinks two-three alcoholic beverages a day C. Declines talking about the trauma D. Learns how to journal his thoughts and feelings

A. Sleeps through the night uninterrupted

A client's response to trauma includes characteristics that relate to which factors? Select all that apply. A. The individual​ B. The traumatic experience C. The recovery environment D. The loss of control

A. The individual B. The traumatic experience C. The recovery environment

The nurse is conducting an initial assessment of a client with post-traumatic stress disorder. To assess the client's perception of the precipitating event that led to the crisis, which question is the most appropriate for the nurse to ask? A. "Why are you seeking help now?" B. "What brings you to the hospital today?" C. "With whom do you live?" D. "Have you been stressed?"

B. "What brings you to the hospital today?"

Which clinical manifestations indicate to the nurse that the client is experiencing post-traumatic stress disorder (PTSD)? Select all that apply. A. Weight gain B. Sleep difficulties C. Hypervigilance D. Irritability E.Learning a new hobby F. Intrusive thoughts G. Trauma

B. Sleep difficulties C. Hypervigilance D. Irritability F. Intrusive thoughts G. Trauma

Which goal is the priority when planning care for a client with post-traumatic stress disorder? A. Increase social skills B. Reduce psychological symptoms C. Provide safety and stabilization D. Develop a value system

C. Provide safety and stabilization

Match the expected outcome to the nursing action it supports.​

Help the client develop two coping mechanisms to help with anxiety attacks. --> The client states "I will exercise 2-3 times a week and use mindfulness exercises to help with anxiety."​ Monitor risk for self-harm and intervene appropriately. --> The client contacts the nurse if feelings of harming self or others appear. Stay with the client when experiencing flashbacks. --> The client uses eye movement desensitization and reprocessing (EMDR) exercises to process traumatic memories and manage reactions. Administer prescribed anti-anxiety medications as needed (PRN).​ --> The client reports being less anxious and able to rest.​

Based upon prescribed orders and nursing standards of care, the nurse needs to determine which nursing actions need immediate action, urgent action, or routine action. Administer a stat anxiolytic medication as prescribed. Provide client teaching on eye movement desensitizing and reprocessing therapy (EMDR). Assess for suicidal ideation. Conduct a head-to-toe shift assessment. Identify triggers and reorient the client. Contract for "no self-harm" for specified time periods.

Immediate Routine Immediate Routine Urgent Urgent

Which client assessment findings would indicate that the client's status improved, declined, or remained unchanged due to the nursing actions? For each finding in the left column, specify if it demonstrates Ricardo's condition has improved, declined, or is unchanged by clicking in the appropriate area. Ricardo states, "I will take alprazolam 0.25 mg no more than three times a day as needed for my anxiety."​ Ricardo states, "I am not ready to talk about the war." Ricardo states, "I was able to sleep last night with no nightmares." Ricardo's wife states, "I have a plan to overdose on my medication to take away the pain." Ricardo is attending psychotherapy sessions once a day.

Improved Unchanged Improved Declined Improved

Nursing interventions are being planned for Ricardo's care needs. Identify if the interventions in the left column are indicated or not indicated for a client who is experiencing post-traumatic stress disorder. The nurse will administer antidepressant medication as prescribed. The nurse will provide client teaching on eye movement desensitizing and reprocessing therapy (EMDR). The nurse will use therapeutic touch to show empathy. The nurse will use silence and listening to encourage expression of feelings. The nurses will require the client to discuss the traumatic experience. The nurse will interact with client at intervals to convey caring and openness and to provide an opportunity to talk.

Indicated Indicated Not indicated Indicated Not indicted Indicated

Post-traumatic stress disorder (PTSD) is a _______ symptom response to a traumatic experience that lasts for more than ________. Symptoms of ________ are common with this disorder and may be serious enough to warrant further attention from care providers.

Multisystem One Month Depression

The nurse has analyzed assessment data and started Ricardo's plan of care. Choose the appropriate nursing diagnoses based on evidence of assessment findings.

Risk for Injury Social Isolation Post-trauma syndrome Hopelessness

The nurse is working with Ricardo, who is seeking care for suicidal ideation. Review the electronic health record before answering the question. Click to select the assessment findings that indicate Ricardo is having a prolonged stress response. 37-year-old man who comes to his primary care provider's office for help, at the urging of his wife due to suicidal ideation without a plan; He was a frontline soldier in the Marine Corp who was honorably discharged in 2020 after serving two tours of duty in Afghanistan. His wife has told him he has "not been the same" since being discharged and it is impacting their relationship. He reports having trouble sleeping, and that he "sleeps with one eye open, " due to frequent nightmares; the client is unwilling to provide specific details of the traumatic war events- stating, "I have never spoken with anyone about them and not sure I ever will." He spends much of his time alone, feels irritable, and feels bad when he gets angry at his wife and children. He states that he finds it difficult to perform his role as a father and duties at work. At the same time, he is easily startled by noise and feels his heart racing "constantly." He describes having disturbing memories and avoids seeing friends from his reserve unit because seeing them reminds him of experiences that he does not want to remember. ​

Suicidal ideation serving two tours in Afghanistan impacting their relationship frequent nightmares spends much of his time alone irritable easily startled disturbing memories

Identify if the characteristic predisposing a client to post traumatic stress disorder (PTSD) is related to the traumatic experience, the individual, or the recovery environment. Each choice will be used once.

The traumatic experience: robbed at gunpoint (severity of stressor) Unexpected death of a child (unanticipated event) The individual: History of alcohol abuse bipolar disorder The environment: friends don't believe them Family lives in another state