delmars Post traumatic stress disorders

. a client recently started on a monoamine oxidase inhibitor (maoi) is experiencing severe headache, tachycardia, and cold, clammy skin. which of the following is the priority nursing intervention? 1. assess the client's blood pressure 2. instruct the client to lie down 3. notify the client's physician 4. offer the client a high-carbohydrate snack

. 1. a toxic and serious adverse reaction to maois is a hypertensive crisis. clinical manifestations of a hypertensive crisis include severe headache, tachycardia, hypertension, and cold, clammy skin. the nurse's priority would be to assess for an increase in blood pressure. a hypertensive crisis can begin abruptly after taking a contraindicated food or drug. immediate medical intervention is indicated when a hypertensive crisis is suspected. it is only after assessing the blood pressure and confirming the diagnosis that interventions can begin.

1. a client has been experiencing irritability, difficulty concentrating, difficulty sleeping, and withdrawal for the past 8 weeks since her house burned to the ground after an explosion. the nurse assesses that this client is experiencing 1. depression. 2. a panic attack. 3. post-traumatic stress disorder. 4. generalized anxiety disorder

1. 3. clients may experience clinical manifestations of post-traumatic stress disorder after experiencing a traumatic event, such as a house burning down. clinical manifestations need to be present for at least 1 month for a diagnosis of post-traumatic stress disorder. the client's clinical manifestations begin abruptly after a traumatic event and last for a period greater than a month.

10. a client tearfully reports having been sexually attacked by a spouse during an argument. the nurse evaluates this situation as 1. an emotional reaction but not a rape, because the couple is married and has had sexual relations. 2. the right of the partner to expect sex because they are married. 3. a rape because sex against one's will is rape. 4. a reaction to the couple's argument that will most likely not happen again.

10. 3. acquaintance rape and marital rape are currently recognized by the court system. the current law allows a person to bring charges against a spouse for rape. awareness continues to be raised that women are individuals with rights and privileges and not property.

11. the client who has been raped tells the nurse, "i am not pressing charges and i'm afraid of seeing my attacker because we live in the sametown." which of the following should the nurse include in the plan of care for this client? 1. assess the client's safety and develop a safety plan 2. encourage the client to change jobs to avoid future encounters with the perpetrator 3. instruct the client not to worry about safety because perpetrators don't attack twice 4. support the client's desire to move to a new town and assume a new identity

11. 1. the client may very well be at risk for future attacks if the perpetrator is known. the nurse needs to make a thorough assessment of the client's safety and assist the client in developing a safety plan in the event the perpetrator is encountered. moving to a new town or changing jobs places the blame and responsibility on the client.

12. During an interview, the nurse observes a client becoming increasingly defensive. the client states, "you wouldn't understand what i've been through." which of the following is the most appropriate response by the nurse? 1. "you're right, i probably won't understand what you've been through." 2. "why are you becoming so defensive?" 3. "sometimes it feels like no one else can understand, but i would like to try." 4. "maybe you will feel better if you concentrate on something else."

12. 3. frequently, clients have experienced things that the nurse has not. by using therapeutic communication skills such as reflecting and empathizing, the nurse can encourage the client to share experiences and begin to understand and develop a therapeutic relationship.

13. which of the following should the nurse include when teaching a class on recognizing post-traumatic stress in children? 1. post-traumatic stress disorder is not diagnosed until the age of 18 2. only physically and sexually abused children and adolescents will experience clinical manifestations of post-traumatic stress disorder 3. school-age children do not experience clinical manifestations of post-traumatic stress disorder because of their developmental level 4. children and adolescents can develop clinical manifestations of post-traumatic stress disorder after experiencing any traumatic event

13. 4. many children and adolescents have experienced natural and man-made disasters in their lives, such as kidnapping, rape, school shootings, peer suicides, fires, and floods. clinical manifestations of post-traumatic stress disorder may develop in children and adolescents after experiencing these types of traumatic events.

14. the nurse is talking with a client who just had a beautiful bouquet of roses delivered. suddenly the client becomes tearful and stares out the window. the client has a history of sexual abuse. which of the following should the nurse include in the plan of care for this client? 1. tell the client that the sexual abuse was in the past 2. tell the client to relax and enjoy the roses 3. give the client some alone time and return later 4. assess if the client is having a flashback

14. 4. clients who have experienced a traumatic event such as sexual abuse may experience flashbacks. the triggers for these flashbacks may be visual, auditory, tactile, or olfactory.

15. a client currently taking fluoxetine (prozac) to decrease clinical manifestations of posttraumatic stress disorder asks the nurse if continuing to take dietary supplements such as saint John's wort, ginseng, and kava kava is acceptable. the most appropriate response by the nurse is which of the following? 1. "if it makes you feel better, continue to take the dietary supplements." 2. "Dietary supplements may interact negatively with your prescribed drugs; check with your care provider." 3. "make sure you take the dietary supplements at a different time." 4. "Dietary supplements are harmless and won't make any difference in how you feel."

15. 2. current studies have shown that dietary supplements may have beneficial uses in decreasing clinical manifestations of mild depression, anxiety, and insomnia when not used in conjunction with prescription drugs. Dietary supplements are not controlled by the food and Drug administration (fDa). studies have shown that taking dietary supplements along with prescription drugs may cause adverse reactions. the client should be encouraged to discuss the amount and type of supplements being taken with the person who is prescribing the drugs.

16. the registered nurse is preparing the clinical assignments for team members on a psychiatric unit. which of the following assignments indicates that the nurse has appropriately delegated assignments? 1. unlicensed assistive personnel attend group therapy with a client 2. a licensed practical nurse assesses a client suspected of having a post-traumatic stress disorder 3. unlicensed assistive personnel sit with a client who is tearful 4. a licensed practical nurse develops a plan of care for a client who experienced a rape trauma

16. 3. unlicensed assistive personnel may sit with a client who is tearful. a licensed practical nurse should not perform the skills of assessing a client or developing a plan of care. these are tasks reserved for the registered nurse. it is not appropriate for unlicensed assistive personnel to attend group therapy with a client.

. 2. a client experiencing post-traumatic stress disorder was started on a monoamine oxidase inhibitor (maoi). which of the following should the nurse include in the medication teaching? select all that apply: [ ] 1. sit up slowly when taking an maoi [ ] 2. report signs of nausea and vomiting [ ] 3. avoid foods such as cheese, salami, and smoked fish [ ] 4. take on an empty stomach [ ] 5. restrict extra fluids [ ] 6. monitor for weight loss

2. 1. 2. 3. maois are a classification of drugs used for post-traumatic stress disorder. they act by blocking an enzyme (monoamine oxidase). clients taking maois should be instructed to sit up slowly to prevent orthostatic hypotension. nausea, vomiting, and weight gain are all adverse reactions. an maoi should be administered with food to prevent gastrointestinal upset. fluids are generally encouraged because constipation is an adverse reaction. clients must avoid foods that contain tyramine when taking an maoi. foods containing tyramine include aged cheese, salami, sauerkraut, beer and wine containing yeast, smoked fish, avocados, fava beans, and caviar. eating foods containing tyramine when taking an maoi can lead to a hypertensive crisis, making this the priority intervention.

4. the nurse assesses which of the following clients to be at the highest risk of developing post-traumatic stress disorder? 1. a client who recently moved to a new city 2. a client who witnessed a fatal shooting 3. a client with a family history of depression 4. a client who has a panic disorder

4. 2. experiencing a traumatic event such as a shooting is an event likely to trigger a posttraumatic stress disorder in a person.

5. a client reports experiencing nightmares and constant worry about the weather since a tornado destroyed the client's house 1 year ago. the nurse assesses that this client is experiencing 1. delusions. 2. panic attacks. 3. flashbacks. 4. hallucinations.

5. 3. a client who repeatedly experiences nightmares and constantly worries about the weather since a tornado destroyed the client's house 1 year ago is experiencing flashbacks. clients who have flashbacks have recurrent intrusive recollections of the traumatic event. clients with delusions, hallucinations, and panic attacks would not reexperience the traumatic event in this way.

6. the nurse assesses a client of rape-trauma syndrome for which of the following expressed style features? select all that apply: [ ] 1. flashbacks [ ] 2. nightmares [ ] 3. crying [ ] 4. restlessness [ ] 5. mood swings [ ] 6. laughing

6. 2. 3. 6. expressed style assessment findings for rape-trauma syndrome are those in which a response is easily observable and include crying, restlessness, and laughing. assessment findings of the reorganization of rape-trauma syndrome occur 2 or more weeks after the rape and include flashbacks, nightmares, and mood swings.

7. a client scheduled to begin relaxation therapy as part of treatment for post-traumatic stress disorder asks the nurse what the purpose is of the relaxation therapy. which of the following is the appropriate response by the nurse? 1. "it will help you not to be frightened anymore." 2. "it will help produce effects that are the opposite of those produced by anxiety." 3. "it will help you learn about your illness." 4. "it will help you learn calming self-talk."

7. 2. relaxation therapy helps the client learn ways to relax the body and reduce the tension produced by anxiety. relaxation therapy does not guarantee that the client will not be frightened anymore. helping a client learn about personal illness is the definition of psychoeducation. helping the client learn calming self-talk defines cognitive restructuring.

8. the nurse is caring for a client working at a high school who witnessed a bombing at the school and is experiencing sadness, sleeplessness, and lack of energy, and appears to be withdrawn. which of the following interventions should the nurse include in the plan for this client? 1. allow the client to talk about the traumatic event in a safe, supportive environment 2. assist the client to look at other career choices and work environments 3. instruct the client that physical exercise may improve the quality of sleep 4. encourage the client to avoid focusing on the event and to make plans for the future

8. 1. allowing clients to talk about traumatic events such as bombings, explosions, and fires enables them to acknowledge their feelings and begin to take control of difficult situations. assisting the client to consider other career choices, to increase physical exercise, to avoid focusing on the event, and to make plans for the future all discourage the client from acknowledging personal feelings.

9. when planning the care of a client who is experiencing post-traumatic stress disorder, the nurse identifies which of the following as an appropriate goal? the client will report 1. spending less time on ritualistic behavior. 2. a decrease in flashbacks and nightmares. 3. having more energy. 4. a decrease in hearing voices.

9. 2. the target clinical manifestation for a client with post-traumatic stress disorder is flashbacks. ritualistic behavior is associated with obsessive-compulsive disorder. having a decreased energy level is associated with depression. hearing voices is associated with schizophrenia.