Psych Chapter 17
A client with post-traumatic stress disorder (PTSD) tells the nurse, "Every morning I wake up with a vicious hangover and swear I'll never drink like that again. Yet, every night I some how end up at the bar." The nurse should consider the possibility of what nursing diagnosis?
Ineffective impulse control
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."
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."
Posttraumatic stress disorder (PTSD) has been diagnosed in a sexually assaulted female client. Which of the following manifestations is the most consistent with PTSD?
Flashbacks
A combat veteran witnessed atrocities on the battle front and was subsequently diagnosed with post-traumatic stress disoder (PTSD). The client admits to the nurse, "I'm stuck in this black, scary pit in my own head, and I honestly don't think I'm ever going to be able to climb out. What nursing diagnosis is most likely for this client?
Hopelessness
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 mostwarrants further assessment for posttraumatic stress disorder?
An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother
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 reviewing the medical records of several clients who have come to the community health center. The nurse would most likely identify a client experiencing which event as being at risk for developing posttraumatic stress disorder (PTSD)? Select all that apply.
Being a survivor of a tsunami that resulted in thousands of deaths Being a marine in a combat situation where the entire platoon was wiped out, except for one person Being hidden in a closet and hearing the entire family murdered by someone who broke into the home Watching televised segments of the moment when the plane hit the second tower on 9/11
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 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
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
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
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
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 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 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 have differing levels of resilience
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 states that the client is often "awake for hours and hours each night."
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 bestinterpret the client's statement?
The client's emotional numbing is a protective mechanism
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
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.
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.
A client with post-traumatic stress disorder is found to have a high propensity for fear. This characteristic is most likely the result of:
characteristics of the client's amygdala and hippocampus.
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.
A nurse is working with a patient who is experiencing large amounts of stress due to relational, financial, and physiologic factors. The nurse can best enhance this patient's resilience by:
helping the patient to think about herself in a positive way.
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.
