Chapter 13: Trauma and Stressor-Related Disorders
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 Explanation: All of the listed components should be included in a comprehensive physical assessment. However, sleep is a major concern in clients with PTSD and is likely disrupted to a greater degree than respiratory function, bowel function, or nutrition.
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." Explanation: The best response by the nurse is one in which the client's concerns about being isolated are validated. Not all interpersonal interactions within a network are supportive. A person can have a large, complex social network but little social support. it is important to remind the client of this and assist the client in identifying alternative forms of social support. It is ineffective and irrelevant to identify which social network category the client is within. Telling the client to reach out to people in the social network assumes the client has positive interpersonal relationships with the people in the network. The nurse must explore the quality of these relationships prior to encouraging the client to reach out. It is not better to be isolated when one is experiencing the symptoms of depression. Social support enhances health outcomes and reduces mortality by helping members make needed behavior changes and buffering stressful life events.
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?
"Acute stress disorder is a possibility, which might develop into PTSD." Explanation: A diagnosis of PTSD requires 1 month of symptoms. Acute stress disorder exists closer to the traumatic event and may develop into PTSD if not resolved. Anxiety is not necessarily self-limiting.
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?" Explanation: Emotions are defined as psychophysiologic reactions that define a person's mood. Emotions are characterized as negative, positive, borderline, or nonemotions. Negative emotions occur when there is a threat to, delay in, or thwarting of a goal or a conflict between goals. Examples of negative emotions include anger and anxiety; therefore, the question that assesses if the client is experiencing negative emotions is "Are you experiencing anger or anxiety?" Asking about pride and relief assesses if the client is experiencing positive emotions. Asking about confusion and awe assesses if the client is experiencing nonemotions. Asking about sympathy and empathy assesses if the client is experiencing borderline emotions.
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." Explanation: Clients with PTSD may have negative feelings associated with themselves. They often tend to believe that they are a burden to others. In such cases, the nurse should give positive feedback to the client for expressing feelings. This encourages the client to be more expressive about personal feelings. Telling the client to calm down and avoid talking would discourage the client from talking. The nurse should avoid using this statement. Telling the client to control the client's anger reinforces the feeling of self-blame in the client, thus this statement should not be used. Saying that looking after the client is the nurse's work indicates that the client is a burden. It reinforces the feeling of self-blame in the client.
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?" Explanation: In determining the client's response to a traumatic event, it is best for the nurse to assess how the client has responded to stress in the past. While all of the other questions may be important to ask in a general assessment, these are not as predictive of the client's ability to cope as a previous response.
Which statement made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms?
"I describe my feelings like I'm having an out-of-body experience." Explanation: Dissociation is a disruption in the normally occurring linkages among subjective awareness, feelings, thoughts, behavior, and memories. A person who dissociates is making himself or herself "disappear." That is, the person has the feeling of leaving his or her body and observing what happens to him or her from a distance and being detached from others. During trauma, dissociation enables a person to observe the event while experiencing no or only limited pain and to protect himself or herself from awareness of the full impact of the traumatic event. Flashbacks are common with PTSD; loud noises associated with the trauma cause flashbacks. Guilt is common for survivors.
The nurse provides care to a client who is newly diagnosed with type 2 diabetes mellitus (DM). Which client statement indicates an adaptation of a healthy coping strategy to deal with this new medical diagnosis?
"I eat fresh, not canned, vegetables every day for lunch." Explanation: Health can be negatively affected by stress when coping is ineffective, and the damaging condition or situation is not ameliorated or the emotional distress is not regulated. The client who is newly diagnosed with type 2 DM will need to adapt to this condition with a healthy diet and exercise. The client statement that indicates a healthy coping strategy is "I eat fresh, not canned, vegetables every day for lunch." Binge watching television shows and driving rather than riding a bike to the park are indicative of a sedentary lifestyle, which should be avoided to decrease the risk for complications associated with type 2 DM. Although alcoholic beverages in moderation is not contraindicated for this client, drinking in excess as evidenced by the client's statement is an example of an unhealthy coping strategy.
Which statement made by the client during the health history and physical examination process indicates to the nurse that the client is experiencing a physical functioning change during a stress response?
"I have a lot of muscle tension in my neck and shoulders." Explanation: Muscle tension is an indicator of a stress response and is classified as a change in physical functioning. Consistent appetite, weight, and sleep patterns are not indicative of a change in physical functioning due to stress.
The nurse includes information regarding methods to enhance sleep for a client who experiences insomnia due to posttraumatic stress disorder (PTSD). Which client statement indicates a need for additional teaching regarding sleep hygiene?
"I have found that drinking a glass or two of wine every night helps me to fall asleep." Explanation: Sleep hygiene is also an important strategy because sleep disruption is common in PTSD. Nurses should collaborate with the client in finding strategies that enhance sleep and manage nightmares. Helpful strategies to enhance sleep include avoiding naps during the day; maintaining the same sleep schedule every day of the week, even on the weekends; and avoiding caffeinated beverages during the late afternoon and early evening hours because caffeine is a strong stimulant that can interfere with sleep. Although alcohol may assist with sleep onset, an alerting effect occurs when it wears off thus causing the client to awaken during the night; therefore, this client statement indicates a need to provide additional teaching regarding sleep hygiene.
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." Explanation: A person who is pessimistic, negative, and refuses to show emotions to others has a type D personality. A person who is introverted, conforming, and avoids conflict has a type C personality. A person who is competitive, impatient, and aggressive has a type A personality. A person who is relaxed, easygoing, and easily satisfied has a type B personality.
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." Explanation: Irritability is a hallmark of hyperarousal. Overeating, loss of sexual interest, and hypersomnia are not associated with hyperarousal.
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." Explanation: A threatened event is just as "real" as an event that culminates in violence. The client's response to medication has nothing to do with corroborating the diagnosis.
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." Explanation: Chronic stress can cause changes in the health of the client and is damaging to their mental and physical health. Stress affects the body's immune system and is damaging to the body systems, including the cardiovascular system. When the immune system is compromised, the symptoms of the client's disease can increase due to a decrease in the body's response. Stress is not physiologically felt as pain but can cause changes to the client's body.
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 get migraine like headaches frequently." -"I am not able to remember anything these days." -"I often have nightmares about the earthquake."
-"I am not able to sleep at night." -"I prefer being alone, all by myself." -"I often have nightmares about the earthquake."
The nurse in an occupational health setting assesses an employee's capacity to withstand the stress of working in a country affected by famine and civil war. Which are factors support the client's resiliency? Select all that apply. -Living in foster care as an infant -Adaptive problem-solving ability -Supportive family and community -Parents/caregivers with substance use disorder -Parenting with authoritative versus permissive or indifferent style
-Adaptive problem-solving ability -Supportive family and community -Parenting with authoritative versus permissive or indifferent style Explanation: The capacity for an individual to be resilient and to manage trauma is based on a complex integration of factors. Having an adaptive capacity to solve problems, being socially connected and able to feel supported and having received parenting from caregivers that includes an authoritarian component more so than a passive style. Growing up in foster care is associated with early attachment challenges and the risk of inconsistent parenting approaches. Similarly, children who grew up with parents with substance abuse can be expected to have a diminished capacity for resilience in general.
A client is diagnosed with posttraumatic stress disorder (PTSD). When assessing the client, which finding would the nurse identify as intrusive? Select all that apply. -Client reports reexperiences a traumatic image -Client relates no longer experiencing dreams -Client states feelings that the event is reoccurring -Client complains of excessive sleeping, usually 12 hours or more per day -Client reports feelings of being suspended in outer space and unable to find a way
-Client reports reexperiences a traumatic image -Client states feelings that the event is reoccurring -Client reports feelings of being suspended in outer space and unable to find a way Explanation: Intrusive thoughts often are associated with cues that symbolize or resemble the original event. Sometimes the traumatic images, thoughts, or perceptions are reexperienced. Nightmares are common. Intrusive symptoms also include dissociative reactions (e.g., feeling or acting as if the event is reoccurring). Sleeping is difficult. Terrifying flashbacks and nightmares often include fragments of traumatic events exactly as they happened.
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. -Educate the client and husband on the effects of spousal abuse. -Confront the husband about the abuse. -Plan an interdisciplinary team meeting regarding this situation. -educate the client on resources available to her
-Consult social services. -Plan an interdisciplinary team meeting regarding this situation. -educate the client on resources available to her
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 -Falling off a playground swing -Urinary incontinence due to a prolapsed bladder
-Personal assault by a family member -Military combat mission where there were casualties -Surviving an EF 4 tornado Explanation: Examples of traumatic events are violent personal assault, rape, military combat, natural disasters, terrorist attacks, being taken hostage, incarceration as a prisoner of war, torture, an automobile accident, or being diagnosed with a life-threatening illness. Falling off a swing is not necessarily a trauma, but a typical accident common to many children. Prolapsed bladder is not a traumatic event and can be easily corrected with various surgical procedures.
The nurse is caring for a client with posttraumatic stress disorder (PTSD). After entering the client's room, the nurse finds that the client is having a flashback episode. Which leads the nurse to reach this conclusion? Select all that apply. -The client appears terrified. -The client is crying and screaming. -The client wakes up suddenly from sleep. -The client curls up in a defensive posture. -The client appears numb with a vacant stare.
-The client appears terrified. -The client is crying and screaming. -The client curls up in a defensive posture. Explanation: A person experiencing a flashback may look extremely terrified, cry and scream, and curl up in a defensive posture. If the client with PTSD wakes up suddenly from sleep, it indicates that the client might have had a nightmare related to the traumatic event. If a client with PTSD appears numb with a vacant stare, it is likely that the client is dissociating.
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 accident took place 2 weeks ago -The client has nightmares about the accident -The client says the client is "unable to face that place again" -The client says the client's family describes the client now as "edgy" and "irritable" -Management is blaming the client for the accident
-The client has nightmares about the accident -The client says the client is "unable to face that place again" -The client says the client's family describes the client now as "edgy" and "irritable" Explanation: Diagnostic criteria for PTSD include avoidance of the site of the trauma, hyperarousal, and nightmares. However, the 2-week time period suggests a diagnosis of acute stress disorder rather than PTSD. The response of management is a stressor but is not among the diagnostic criteria.
A nurse is assessing a client with posttraumatic stress disorder (PTSD). Which symptoms in the client would indicate a need for hospitalization? Select all that apply. -The client has suicidal tendencies. -The client avoids engaging in social activities. -The client has negative feelings about the self. -The client is not able to sleep well. -The client is overwhelmed with flashbacks of the traumatic event.
-The client has suicidal tendencies. -The client is overwhelmed with flashbacks of the traumatic event. Explanation: Clients with PTSD do not usually need hospitalization. Short inpatient stays may be necessary if the client is suicidal or is overwhelmed with flashbacks of the traumatic event. Avoiding social activities, having negative feelings about oneself, and inability to sleep are not the criteria for hospitalizing clients with PTSD.
A nurse is caring for a client who has been recently robbed at gunpoint. Which physical responses should the nurse expect to identify during the assessment? Select all that apply. -sleep disturbances -a change in weight -hyperactivity -muscle tension -disheveled appearance
-sleep disturbances -a change in weight -muscle tension -disheveled appearance Explanation: Physical functioning usually changes during stressful events. Sleep is disturbed, appetite either increases or decreases, and sexual activity can change. Anxiety is expressed in body language as muscle tension. Muscle tension is a condition in which muscles of the body are partially contracted for extended periods of time. Muscle tension is typically caused by the physiological effects of stress. Physical appearance may be uncharacteristically disheveled which is a projection of the person's feelings. Hyperactivity is not a symptom of a traumatic event.
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?
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?
Which client should the nurse assess most closely for signs and symptoms of posttraumatic stress disorder (PTSD)?
A service member in the military who has recently returned from two tours of duty Explanation: A wide variety of stressors can cause PTSD. However, members of the military are at particularly high risk.
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 Explanation: It is highly plausible that the client has post-traumatic stress disorder, given the high incidence and prevalence among veterans. Assessment should precede any interventions such as family meetings or education sessions.
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 Explanation: In an emergency context, the assessment of suicidality and the risk for self-harm is a priority. The nurse should perform each of the other listed actions, but measures to ensure the client's safety are paramount.
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 Explanation: Intrusion almost always takes a toll on the client's sleep. Communication and social support are only peripherally related to episodes of intrusion. Intrusion will certainly affect the client's vital signs, but these changes are unlikely to be as problematic as sleep difficulties.
A client developed posttraumatic stress disorder (PTSD) after a motor vehicle accident and is scheduled to begin cognitive processing therapy. What outcome should the advanced practice nurse identify when planning this type of therapy?
Client will describe the effects of PTSD on the client's activities of daily living Explanation: A focus of cognitive processing therapy is identifying the effects of PTSD on daily life. It does not focus directly on stress management techniques or family engagement. Complete control of the fear response is an unrealistic goal of cognitive behavioral therapy.
Which of the following disorders involves the emergence of varying personalities in a person that is associated with stress and conflict?
Dissociative identity disorder Explanation: Dissociative identity disorder (DID) occurs when a person is dominated by at least one of two or more definitive personalities at one time. It is associated with psychosocial stress and conflict. Dissociative amnesia is characterized by the inability to recall an extensive amount of important personal information because of physical or psychological trauma. Dissociative fugue occurs when a person suddenly and unexpectedly leaves home or work and is unable to recall the past. In depersonalization disorder, the client experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality.
A nurse is caring for a client with posttraumatic stress disorder (PTSD). During the assessment interview, the nurse finds that the normally calm client at times becomes very aggressive and uses abusive language. When in the aggressive state, the client fails to recognize personal information. What is this behavior indicative of?
Dissociative identity disorder Explanation: In dissociative identity disorder, formerly multiple personality disorder, the client displays two or more distinct identities or personality states. Clients in this state have an inability to recall important personal information. In dissociative amnesia, the client cannot remember important personal information. In depersonalization disorder, clients have a persistent or recurrent feeling of being detached from their mental processes or body. Through avoidance behavior, clients with PTSD try to repress any feelings, thoughts, or emotions associated with the traumatic event.
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 Explanation: Facing and conquering challenges increases self-worth, self-efficacy, and resilience. This type of activity is unlikely to have a direct effect on participants' risks of somatic symptom disorders or personality disorders, which have complex etiologies. Participants' coping is likely to be enhanced, but hyperarousal is associated with poor coping and low resilience.
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 Explanation: The essential feature of these disorders involves a failure to integrate identity, memory, and consciousness. That is, unwanted intrusive thoughts disrupt one's contact with the here and now, or memories that are normally accessible are lost. These disorders are closely related to trauma- and stressor-related disorders but are categorized separately.
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?
Flashback Explanation: A flashback can occur as the result of an intrusive memory of trauma and it can be triggered by sensory input. The flashback involves a sensory re-experiencing of the trauma. A dissociation is an interruption of the normal level of awareness impairing feelings, behavior and memories. A hallucination is an alteration of perception in the moment. Derealization involves transitory feeling of unreality and losing connection with the present.
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? Explanation: Sleep is profoundly affected by PTSD; sleep assessment is a key aspect of the physical assessment. It is also necessary to assess the client's diet and activity, but sleep is more likely to be an issue. Bowel function is a secondary concern for most clients.
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 Explanation: It is imperative to establish a therapeutic relationship with clients and to enlist their social support network. However, the client's risk of suicide is a priority because of the immediate safety implications. Affirming the client is important, but safety is a priority.
A nurse is interviewing several clients who survived a school shooting ten years ago when they were in high school. Which clients should the nurse identify as having achieved adaptation following this event? Select all that apply. -Nurse manager for the local hospital. -Married, mother of three, who is a stay at home mother. -Single father with a history of spousal abuse. -Local lawyer with a history of drug addiction. -Father of two who works in a tire store and has a second job as a mechanic.
Nurse manager for the local hospital. Married, mother of three, who is a stay at home mother. Father of two who works in a tire store and has a second job as a mechanic. Explanation: Adaptation is a person's ability to survive and flourish after a traumatic event. The nurse manager, stay at home mother, and the mechanic show no evidence of maladaptation. Negative emotions such as anger can be a result of an inability to cope with the stressful event. A lack of successful coping can lead to poor coping choices such as drugs and alcohol. Some maladaptive coping strategies increase the risk for mortality and morbidity, such as the excessive use of alcohol, drugs, or tobacco.
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 Explanation: Reactive attachment disorder is characterized by the inability to form positive attachments due to prior neglect. Culturally safe care is always necessary but does not address this child's diagnosis. Teaching about resilience is also relevant but similarly does not address this particular diagnosis that the child already has. Disruptive behavior disorder is not a primary consideration.
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 Explanation: Lorazepam is a benzodiazepine that is used to reduce anxiety. Improvements in mood and energy and relief of nightmares would be indirect results of the reduction in 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?
Sleep pattern disturbance related to recurrent nightmares Explanation: The appropriate nursing diagnosis is sleep pattern disturbance. The client is not having illusions, nor is the client's fear of the fire unrealistic. The client is not experiencing ego disintegration.
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 Explanation: Disinhibited social engagement disorder is characterized by being overly familiar with strangers. The disorder is not primarily associated with family boundaries, disruptive thoughts, or the management of conflict.
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. Explanation: Acute stress disorder is differentiated from PTSD in that symptoms occur during or immediately after the trauma and last for at least 2 days. If symptoms do not resolve within 4 weeks after the conclusion of the event, the diagnosis is changed to PTSD. The two diagnoses are not differentiated on the basis of response to alternative therapies, the presence of a one-time causative event, or changes in the client's routine in response to anxiety.
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 benefits from supportive touch. Explanation: The client is having a flashback experience and holds the nurse's hand. This indicates that the client feels safe with touch and that supportive touch would be beneficial for the client. Holding the nurse's hand does not indicate that the client is dissociating. If the client appears numb with a vacant stare it is likely that the client is dissociating. The client must already be terrified by the flashback episode. Holding the nurse's hand does not indicate that the client is taking a defensive posture.
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. Explanation: Limiting the number of staff members who interact with the client would help the client to become familiar with and trust the staff. This is the most appropriate reason for only one nurse being assigned to the client. Clients hospitalized with PTSD need equally good care as that given any other client in the psychiatric facility. If the client has developed trust in the nurse, then the client may be better able to express feelings. Limiting the number of staff members attending to the client would not directly help increase the effectiveness of therapy.
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. Explanation: A client with PTSD usually has difficulties in maintaining relationships. This occurs because the ability to build trust is severely impaired in them. Issues such as irritability, negativity, and having dissociative disorder would have already been treated if the client has had proper treatment.
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 easily startled by sudden noises Explanation: A person who is hyperaroused is often easily startled. Fatigue, scattered speech, and reluctance to discuss a trauma are consistent with a diagnosis of PTSD, but these are not direct indications of hyperarousal.
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 Explanation: The client's statement suggests depersonalization, which is an avoidance response to PTSD. This needs to be directly addressed but not necessarily in an inpatient setting. Assessment for suicide risk is necessary for all clients with PTSD, but the presence of derealization does not indicate an acute risk. Depersonalization is not a direct result of hyperarousal, though the two phenomena can certainly coexist.
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 Explanation: "Spacing out" is an example of dissociation (depersonalization). It is not uncommon for the client with PTSD to experience failure of coping skills, sleep disturbances, and reluctance to acknowledge moods, but these are not evidences of dissociation.
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. Explanation: Exposure therapy is used to treat avoidance behavior in clients with PTSD. The therapy may help the client face and control the thoughts regarding the traumatic event. This therapy does not directly cause improvement in social activity or sleep quality or prevent dreams from occurring.
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 have dissociative symptoms. Explanation: Clients with PTSD are likely to have dissociation. It is a protective defense mechanism that helps the client to protect himself or herself from recognizing the effects of the traumatic event by allowing the mind to forget or remove itself from the painful memory. Dissociation could be manifested as the client speaking in a different tone of voice or appearing numb with a blank stare. This is not a manifestation of unconsciousness. Psychotherapy is used to help the client be more expressive. Illicit drug use is not likely to cause this behavior.
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 be physically safe. Explanation: The client is at risk of committing suicide. The therapy should first be focused on keeping the client physically safe. Expression of emotions, establishing a social support system, and ability to deal with stress are all the goals of therapy for a client with PTSD. These goals should be established once the safety of the client is ensured.
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 Explanation: The nurse should use touch with great caution when working with a client who has experienced a sexual assault. There is no clear need for two caregivers to be present during an assessment. If medications have been prescribed, the nurse should never encourage the client to not take them. The client's support network should be accessed as much as possible.
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 Explanation: Speaking softly and gently to the client indicates professional behavior with a nonthreatening demeanor. An authoritarian behavior could trigger feelings of fear in a client with PTSD. This behavior will not help induce sleep in the client. Before approaching the client, the nurse should be well aware of the client's experience and behavior. Talking to the client in a soft tone would not always help calm down the client. One of the goals of therapy is to let the client express repressed feelings of anger and rage. Clients' expression of anger should be encouraged in a nonthreatening manner.
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?
Use supportive touch after asking for the client's permission. Explanation: When the client is experiencing a flashback of a violent event, the nurse must use supportive touch only after obtaining the client's permission. The use of touch conveys that the client is not alone and that the nurse is always with the client. Leaving the client alone would make the client more scared and isolated. If touching the client without prior permission, a client experiencing a flashback may respond aggressively or defensively. It is not the time to ask the client to lie down properly.
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 Explanation: The risk for suicide or other forms of self-harm is high in clients with PTSD. MAOIs are not used to treat the disorder, and delusions and hallucinations rarely occur. Social isolation is common among patients with PTSD; inappropriate social interactions, however, are less common.
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. Explanation: Exposure therapy may involve a visit to the place where a traumatic event occurred. Reflection, family meetings, and support groups may be components of the client's broader treatment plan, but they are not exposure therapy.
A psychiatric-mental health nurse is teaching the family members of a client about strategies for engaging with their family member who has recently been diagnosed with posttraumatic stress disorder (PTSD). The nurse should encourage the client's family to:
anticipate that the client is likely to be irritable and withdrawn at times. Explanation: Clients with PTSD are prone to irritability and social withdrawal. In most cases, it is counterproductive and unethical to force a client into social situations if he or she is openly opposed to them. Sleep disruptions are expected, but there is no recognized pattern of frequent naps; insomnia is typical. Benzodiazepines are not normally used for the treatment of PTSD.
A client has experienced a physcial assault and states "I keep having nightmares about it." Which intervention may be most helpful for the nurse to explore with the client at this time?
debriefing about the event Explanation: The client who has experienced a traumatic event such as a physical assault may benefit from debriefing which involves the client reconstructing the event. While exercise may be beneficial in general, it is not a specific treatment related to a traumatic event. It is premature to plan prescription of a sleep aid or hospitalization before trying other measures with debriefing or counseling
A client continues to complain of chest pain and headaches after a disaster, even though all diagnostic tests are negative. In looking at risk factors for these symptoms, what would the nurse assess for?
post-traumatic stress disorder Explanation: Clients can continue to have unexplained physical symptoms after a disaster. Risk factors for these include having post-traumatic stress disorder. Another risk factor is high physical injury based upon the disaster, not a lack of physical injury. Amount of involvement in the disaster would not have a bearing on unexplained symptoms since these can occur in those who are directly traumatized and the nontraumatized. While family support is important in helping a client cope with a disaster, this would not be a factor in unexplained symptoms- additionally there are other methods of support such as friends or coworkers.