Varcarolis Ch. 16 Trauma, Stressor-Related, and Dissociative Disorders

A nurse observes that a child is withdrawn from her parents and does not interact much with them. On inquiry, the nurse finds that the child has been a victim of domestic violence and does not interact with anybody. Which clinical condition is the child likely to have? a. Separation anxiety b. Developmental delays c. Reactive attachment disorder d. Disinhibited social engagement behavior

c

Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? A. " I attend my therapy sessions regularly." B. " Those intrusive memories are hidden for a reason and should stay hidden." C. " Keeping busy is the key to getting mentally healthy." D. " I've agreed to move in with my parents so I'll get the support I need."

A. " I attend my therapy sessions regularly."

What information should the nurse give to the family of a client who has had a dissociative episode? A. Dissociation is a method for coping with severe stress. B. Dissociation suggests the possibility of early dementia. C. Brief periods of psychotic behavior may occur. D. Ways to intervene to prevent self-mutilation and suicide attempts.

A. Dissociation is a method for coping with severe stress. Childhood physical, sexual, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms.

Which item of data routinely gathered during assessment of a client with dissociative disorder would be of least relevance to planning? A. Voluntary control of symptoms B. Ability to remember C. Level of anxiety D. Evidence of disorientation

A. Voluntary control of symptoms Clients with dissociative disorders do not have voluntary control of symptoms. Voluntary control of symptoms has greater relevance when the nurse is assessing clients with somatoform disorders.

Use of dissociation most closely resembles: A. performing mundane tasks on autopilot. B. developing a headache to avoid an unpleasant task. C. feeling angry with a co-worker who shirks work. D. finding a socially acceptable reason to meet a need.

A. performing mundane tasks on autopilot. Mild, fleeting dissociative experiences are relatively common to all of us; for example, we say we are on "automatic pilot" when we drive home from work and cannot recall the last 15 minutes before reaching the house.

When a toddler's mother is hospitalized for several months, the nursing diagnosis Risk for impaired parent/child attachment related to: prolonged separation has been included into a child's plan of care. The most appropriate outcome would be that: A. the mother is discharged and returned home as soon as possible. B. mother and child show signs of healthy bonding. C. the father is able to assume the mother's role in her absence. D. the child is able to transfer nuturing needs to another available adult.

B. mother and child show signs of healthy bonding. An overall attachment outcome would be for the parent and infant/child to demonstrate an enduring affectionate bond.

A child who is able to regain mental stability after a traumatic event is said to be: A. autonomous. B. resilient. C. mature. D. independent.

B. resilient. The term resilience refers to positive adaptation, or the ability to maintain or regain mental health despite adversity.

A child reared in a minority culture is at greatest risk for: A. eating- and sleep-related disorders. B. traumatic experiences in early childhood. C. bullying. D. homicidal thoughts.

B. traumatic experiences in early childhood. Poverty, parental substance abuse, and exposure to violence have received increasing attention and place minority children at greater risk for trauma and stress.

A nurse who is caring for traumatized children of various cultural backgrounds must first: A. become familiar with the various cultures. B. gain the children's trust. C. become aware of any personal biases. D. convince the parents that their children require care.

C. become aware of any personal biases. Working with children and adolescents from diverse backgrounds requires an increased awareness of one's own biases, as well as the patient's needs.

A child who was physically and sexually abused is at great risk for: A. depression. B. suicide attempts. C. bullying and abusing others. D. becoming active in a gang.

C. bullying and abusing others. Children who have been abused are at risk for abusing others, as well as for developing dysfunctional patterns in close interpersonal relationships.

According to the Attachment Theory, relationship disorders are related to trauma associated with: A. insufficient food and/or shelter. B. siblings and/or strangers. C. caregivers and/or parents. D. culture and/or religion.

C. caregivers and/or parents. Attachment patterns or schemas are formed early in life through interaction and experiences with caregivers, and this relationship is embedded in implicit emotional and somatic memories.

A client diagnosed with PTSD shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that the next medication to be prescribed will be a: A. beta blocker. B. barbiturate. C. tricyclic antidepressant (TCA). D. sedative.

C. tricyclic antidepressant (TCA). TCAs or mirtazapine (Remeron) maybe be prescribed if SSRIs or SNRIs are not tolerated or do not work.

A nurse conducts an initial interview with a veteran of two tours in the war with Iraq. The veteran says, "The war was years ago, but I still remember my friends who were killed. I don't know why I lived and they died." What is the nurse's priority response? a. "Are you having any thoughts of harming yourself?" b. "It's important to think about how good your life is now." c. "Are you saying you have some guilt about being a survivor?" d. "The outcomes of war are tragic and stay with us for many years."

a

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? A. A 13-year-old male B. A 10-year-old female C. A 7-year-old male D. A 4-year-old female

D. A 4-year-old female The developing brain is particularly vulnerable to adverse events because the most rapid brain development occurs in the first five years of life. The right hemisphere is involved in processing social-emotional information, promoting attachment functions, regulating body functions, and in supporting the individual in survival and in coping with stress. Since the right brain develops first and is involved with developing templates for relationships and regulation of emotion and bodily function, early attachment relationships are particularly important for healthy development and life-long health.

Which statement about structural dissociation of the personality is true? A. An organic basis exists for this type of disorder. B. Nurses perceive clients with this disorder as easy to care for. C. No known link exists between this disorder and early childhood loss or trauma. D. This disorder results in a split in the personality causing a lack of integration.

D. This disorder results in a split in the personality causing a lack of integration. The theory of structural dissociation of the personality proposes that patients with complex trauma have different parts of their personality, the apparently normal part and the emotional part, that are not fully integrated with each other. Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors. These different parts may not be aware of each other, with only one dominant personality operating depending on the situation and circumstance of the moment.

The nurse is planning care for a patient diagnosed with a dissociative disorder. Which intervention is directed primarily towards minimizing the patient's anxiety level? Select all that apply. a. Provide a simple, predictable daily routine. b. Teach and reinforce relaxation and deep breathing techniques. c. Work with the patient and involved parties to reestablish relationships. d. Allow the patient to progress at his or her own pace as memories are recovered. e. Provide support through empathetic listening during disclosure of painful experiences.

abd

A nurse is caring for a child who needs treatment for mental trauma. Place the stages of the staged treatment protocol in the correct order. a. Provide safety. b. Reduce arousal. c. Nurture self-awareness. d. Teach coping skills.

abdc

1. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support numbing as a temporary way to manage intolerable feelings.

b. Explain that the physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the bodys responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

17. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, If theres a loud noise at night, I get under my bed because I think were getting bombed. What type of experience has the soldier described? a. Illusion c. Nightmare b. Flashback d. Auditory hallucination

b. Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

3. After the sudden death of his wife, a man says, I cant live without her she was my whole life. Select the nurses most therapeutic reply. a. Each day will get a little better. b. Her death is a terrible loss for you. c. Its important to recognize that she is no longer suffering. d. Your friends will help you cope with this change in your life.

b. Her death is a terrible loss for you. Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

A patient with dissociative identity disorder reports an increased awareness of his or her surroundings and a reduction in dissociative episodes. Which instruction provided by the nurse while teaching the grounding techniques helped the patient to alleviate symptoms? a. "Have a positive insight." b. "Write your feelings in a diary." c. "Hold an ice cube in your hand." d. "Sit straight and upright in the chair."

c

10. A patient states, I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school. This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

c. Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system c. Sympathetic nervous system b. Peripheral nervous system d. Parasympathetic nervous system

c. Sympathetic nervous system The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

15. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

c. depression. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

A 35-year-old army combat veteran is being treated for migraines and hypertension. The nurse is particularly interested in the individual's response to which mental health-focused question? a. "Are you worried about anything in particular? b. "Is there any history of suicide in your family?" c. "Have you ever experienced a hallucination?" d. "How would you describe posttraumatic stress disorder?"

d

Which statement about structural dissociation of the personality is true? a. An organic basis exists for this type of disorder. b. Nurses perceive patients with this disorder as easy to care for. c. No known link exists between this disorder and early childhood loss or trauma. d. This disorder results in a split in the personality, causing a lack of integration.

d

22. A soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family, but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response. a. Posttraumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support.

d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support. Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used."

"We spend daily family time talking about experiences and feelings."

Hallie's father, Brent, has now been diagnosed with PTSD as well as Hallie. Which of the following symptoms would lead a provider to suspect PTSD? (select all that apply): - Visiting the scene of the accident over and over - Talking with strangers about the events of the accident - Flashbacks of the accident - Hypervigilance - Irritability - Difficulty concentrating - Mania

- Flashbacks of the accident - Hypervigilance - Irritability - Difficulty concentrating All these symptoms are signs of PTSD. The other options are not associated with signs of PTSD.

The symptoms of an adjustment disorder can include:(Select all that apply.) - Guilt - Social withdrawal - Overachieving - Anger - Depression

- Guilt - Social withdrawal - Anger - Depression In contrast to acute stress disorder responses, which are quite severe and include anxiety and fear, symptoms of an adjustment disorder can run the gamut of all forms of distress including guilt, depression, and anger. These feelings may be combined with other manifestations of distress, including physical complaints, social withdrawal, or work or academic inhibition.

A nurse has been caring for a patient with posttraumatic stress disorder. Which patient behaviors indicate an improved ability to cope? Select all that apply. a. The patient has improved eye contact. b. The patient asks for help when required. c. The patient has fewer physical complaints. d. The patient shows improved grooming skills. e. The patient tries to find information about treatment.

bce

When discussing the symptoms of PTSD, the nurse correctly states: A. "The symptoms can occur almost immediately or can take years to manifest." B. "PTSD causes agitation and hypervigilance but rarely chronic depression." C. "When experiencing a flashback, the client generally experiences a slowing of responses." D. "PTSD is an emotional response that does not cause significant changes in brain chemistry."

A. "The symptoms can occur almost immediately or can take years to manifest." The onset of PTSD symptoms can occur as early as a month after exposure, but a delay of months or years is not uncommon.

The symptom the nurse can expect a client with depersonalization disorder to manifest is: A. aimless wandering with confusion and disorientation. B. a feeling of detachment from one's body or mental processes. C. existence of two or more personalities that take control of behavior. D. worry about having a serious disease based on symptom misinterpretation.

B. a feeling of detachment from one's body or mental processes. Depersonalization is characterized by a sense of unreality or self-estrangement.

Empathic listening is therapeutic because it focuses on: A. enhancing self-esteem. B. lessening feelings of isolation. C. reducing anxiety. D. encouraging resilience.

B. lessening feelings of isolation. Empathic listening can be healing because it can help minimize feelings of isolation.

Erin has just been diagnosed with dissociative identity disorder. She asks you, "What exactly are 'alters'? My provider told me I have several of them." Which statement by Erin illustrates that the education you provided has been effective? A. "So, alters are based in mysticism and religiosity, such as demons." B. "So, alters are separate personalities with their own characteristics that take over during stress." C. "So, alters are never aware of each other." D. "So, alters are just like me, but they have no memory of the trauma I went through."

B. "So, alters are separate personalities with their own characteristics that take over during stress." Dissociative identity disorder appears to be associated with at least two dissociative identity states: one is a state or personality that functions on a daily basis and blocks access and responses to traumatic memories, and another state (also referred to as an alter state) is fixated on traumatic memories. Each alter has its own memories, behavior patterns, and characteristics. Transition from one personality to another (switching) occurs during times of stress. The other responses are incorrect, because alters may be aware of the existence of each other to some degree, and alters are not just like the host—they have different behaviors and memories.

Which of the following statements about dissociative disorders is true? A. Dissociative symptoms are under the person's conscious control. B. Dissociative symptoms are not under the person's conscious control. C. Dissociative symptoms are usually a cry for attention. D. Dissociative symptoms are always negative.

B. Dissociative symptoms are not under the person's conscious control. Dissociation is involuntary and results in failure of the normal control over a person's mental processes and normal integration of conscious awareness. The other responses are untrue.

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? A. Overeating B. Hypervigilance C. A drive to be perfect D. Passivity

B. Hypervigilance PTSD in preschool children may manifest as irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance.

The care plan of a male patient diagnosed with a dissociative disorder includes the nursing diagnosis ineffective coping. Which behavior demonstrated by the patient supports this nursing diagnosis? A. Has no memory of the physical abuse he endured. B. Using both alcohol and marijuana C. Often reports being unaware of surroundings. D. Reports feelings of "not really being here"

B. Using both alcohol and marijuana

Which statement accurately describes the effects of emotional trauma on the individual physically? A. Emotional trauma is a distinct category and unrelated to physical problems. B. The physical manifestations of emotional trauma are usually temporary C. Emotional trauma is often manifested as physical symptoms D. Patients are more aware of the physical problems caused by trauma

C. Emotional trauma is often manifested as physical symptoms

Which goal should be addressed initially when providing care for 10-year-old Harper who is diagnosed with Posttraumatic stress disorder? A. Harper will be able to identify feelings through the use of play therapy. B. Harper and her parents will have access to protective resources available through social services. C. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts. D. Harper and her parents will demonstrate an understanding of the human response to traumatic events.

C. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts

Syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered: A. dissociative disorders such as dissociative identify disorders. B. physical disorders, not mental disorders. C. culture-bound syndromes that are not dissociative disorders. D. myths, or rumors, because they have not been sufficiently studied to be classified as real.

C. culture-bound syndromes that are not dissociative disorders. Certain culture-bound disorders exist in which there is a high level of activity, a trancelike state, and running or fleeing, followed by exhaustion, sleep, and amnesia regarding the episode. These syndromes, if observed in individuals native to the corresponding geographical areas, should be differentiated from dissociative disorders. The other responses are incorrect.

An appropriate intervention for stage 2 of the staged model of trauma treatment is: A. re-enforcing social skills training. B. providing a predictable environment. C. engaging in memory work. D. role-modeling problem-solving skills.

C. engaging in memory work. Appropriate interventions for stage 2 of the staged model of trauma treatment include reducing arousal and regulating emotion through symptom reduction; engaging in memory work while reducing arousal; finding comfort from others; tolerating affect; integrating disavowed emotions and accepting ambivalence, overcoming avoidance; improving attention and decreasing dissociation; working with memories; and transforming memories.

Hallie, 4 years old, is referred to the outpatient mental health clinic after being in a severe car accident during which her father was driving and her mother died. Her father states she is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. Hallie states to you, "It's my fault because I'm bad." You suspect: A. adjustment disorder. B. dissociative identity disorder. C. posttraumatic stress disorder (PTSD). D. acute stress disorder (ASD).

C. posttraumatic stress disorder (PTSD). PTSD in preschool children may manifest as repetitive play that includes aspects of the traumatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. Children may blame themselves for the traumatic event and manifest persistent negative thoughts about themselves. Unlike PTSD, adjustment disorder may be diagnosed immediately or within 3 months of exposure. Responses to the stressful event may include combinations of depression, anxiety, and conduct disturbances. Dissociative identity disorder includes the presence of "alters" or other personalities that take over in times of stress. As compared with PTSD that occurs a month after the trauma, ASD occurs from 3 days and up to 1 month after exposure to a highly traumatic event. Individuals with ASD experience three or more dissociative symptoms either during or after the traumatic event, including the following: a sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (experience of a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory).

The school nurse has been alerted to the fact that an 8 year old boy routinely playacts as a police officer "locking up" other children on the playground to the point where the children get scared. The nurse recognizes that this behavior is most likely an indication of: A. the need to dominate others B. Inventing traumatic events. C. the need to develop close relationships D. A potential symptom of traumatization

D. a potential symptom of traumatization

Dissociative identity disorder is characterized by: A. the inability to recall important information. B. sudden, unexpected travel away from home and inability to remember the past. C. the existence of two or more subpersonalities, each with its own patterns of thinking. D. recurring feelings of detachment from one's body or mental processes.

D. recurring feelings of detachment from one's body or mental processes. Dissociation is an unconscious defense mechanism that protects the individual against overwhelming anxiety through an emotional separation. However, this separation results in disturbances in memory, consciousness, self-identity, and perception.

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. The nurse explains that: A. children this age usually have imaginary friends. B. it is nothing to worry about unless the child starts to socially isolate. C. the child needs more of their one-on-one attention. D. the imaginary friend is a coping mechanism the child is using.

D. the imaginary friend is a coping mechanism the child is using. Often traumatized children feel responsible for what happened to them and are frightened by flashbacks, amnesia, or hallucinations that may be due to trauma. For example, a child may use imaginary friends as a coping mechanism.

The nurse is assessing a young child for posttraumatic stress disorder (PTSD). What does the nurse include in the assessment? Select all that apply. a. Bowel habits b. Motor function c. Blood pressure d. Speech patterns e. General appearance f. Characteristics of play

bdef

A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine

a

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

a

Which assessment tool does the nurse use while assessing a patient with dissociative identity disorder? a. Somatoform questionnaire b. Child dissociative checklist c. Child sexual behavior inventory d. Posttraumatic stress disorder screening

a

1. A young adult says, I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I dont remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them. Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

a. Acute stress disorder b. Depersonalization disorder d. Posttraumatic stress disorder Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patients presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

8. Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of blackouts despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are lost to the patient (blackouts). See relationship to audience response question.

23. Which assessment finding best supports dissociative fugue? The patient states: a. I cannot recall why Im living in this town. b. I feel as if Im living in a fuzzy dream state. c. I feel like different parts of my body are at war. d. I feel very anxious and worried about my problems.

a. I cannot recall why Im living in this town. The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. See relationship to audience response question.

20. A soldier in a combat zone tells the nurse, I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind. Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? a. Reexperiencing c. Avoidance b. Hyperarousal d. Psychosis

a. Reexperiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

3. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside. These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited.

a. Vital signs return to normal.

2. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) a. conveying empathy and acknowledging the childs distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

a. conveying empathy and acknowledging the childs distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. e. staying with the child until the anxiety decreases. The childs symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the childs distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

25. Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

a. engage the parasympathetic nervous system. In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

9. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: a. risk for self-harm. c. memory impairment. b. cognitive function. d. condition of self-esteem.

a. risk for self-harm. Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

A nurse is assessing a child who has witnessed violence at home. What should the nurse document when completing an admission genogram of the child? Select all that apply. a. Relationships b. Investigations c. Family history d. Laboratory testing e. Family composition

ace

The nurse is caring for a patient with dissociative amnesia disorder. The patient gets extremely aggressive due to anxiety and causes physical harm to him or herself and to others. Which nursing intervention does the nurse follow to reduce anxiety and aggression in the patient? a. The nurse lets the patient make decisions on major issues. b. The nurse frequently observes the patient by visiting the patient's room. c. The nurse reminds the patient about the happy moments of the patient's life. d. The nurse prepares a schedule and instructs the patient to follow it regularly.

b

A nurse is performing an assessment of a child diagnosed with disinhibited social engagement disorder. Which behavior should the nurse expect to find in the child? a. The child throws stones at strangers. b. The child willingly goes with a stranger. c. The child cries when touched by a stranger. d. The child hides when a stranger approaches

b

A nurse prepares the plan of care for a school-age child diagnosed with reactive attachment disorder. Which initial outcome should be the focus of the nurse's intervention? The child will: a. Decrease impulsive behavior b. Express feelings through journaling c. Verbally recount traumatic experiences d. Correctly identify the date, time, and place

b

Which child should be assessed for possible posttraumatic stress disorder (PTSD) as a result of exposure to major trauma in his or her life? Select all that apply. a. A 3-year-old whose older sibling was born with both physical and cognitive impairments. b. A 4-year-old who was hospitalized for two months after being injured in an automobile accident. c. An 8-year-old child who has a medical history that includes several broken bones and a dislocated shoulder. d. A 5-year-old child who lives with grandparents since his or her single parent was deployed by the military 10 months ago. e. A 12-year-old who has been in cancer remission for three years since finishing both chemotherapy and radiation treatments.

bcde

12. A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patients behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

b. Engage the patient in a physical activity such as exercise. Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

14. The gas pedal on a persons car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this persons cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

16. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention? a. Its good to be home. I missed my home, family, and friends. b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. d. I want to continue my education, but Im not sure how I will fit in with other college students.

b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

11. The unlicensed assistive personnel (UAP) says to the nurse, That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her? Select the nurses best reply. a. Spend as much time with her as you can and ask questions about her life. b. Use short, simple sentences and keep the environment calm and protective. c. Provide more information about her past to reduce the mysteries that are causing anxiety. d. Structure her time with activities to keep her busy, stimulated, and regaining concentration.

b. Use short, simple sentences and keep the environment calm and protective. Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patients time should not be loaded with demanding or stimulating activities.

Which behavior would support a diagnosis of posttraumatic stress disorder (PTSD) in a preschool child? Select all that apply. a. Engages in specific, ritual behaviors b. Frequent displays of irritability and negativity c. Reluctant to engage in previously enjoyed activities d. Expresses concern that "something bad is going to happen" e. Shares that he or she "hears voices when there is no one there"

bcd

A nurse is caring for an adult patient who has trauma-related disorder. The patient reports to the nurse that he has started using relaxation techniques and is sleeping better. How should the nurse interpret this behavior? a. The patient is feeling nervous. b. The patient is feeling less confident. c. The patient is able to manage anxiety. d. The patient has improved self-esteem.

c

A nurse is developing a plan of care for a patient with dissociative amnesia. Which strategies should the nurse include in the plan? a. Allow the patient to rest. b. Ask the patient to recollect past events. c. Instruct the patient on grounding techniques. d. Ask the family member to make routine decisions.

c

When caring for a child with posttraumatic stress disorder, which intervention should the nurse include in the patient plan of care? a. Provide changeable environment. b. Help patient learn positive avoidance. c. Reduce stimulation of traumatic memories. d. Promote arousal to build tolerance to stress.

c

4. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks. PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individuals extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, If you had given him your undivided attention, he would still be alive. How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

c. Anger is an expected emotion in an adjustment disorder.

21. A soldier who served in a combat zone returned to the U.S. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing c. Avoidance b. Hyperarousal d. Psychosis

c. Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

24. After major reconstructive surgery, a patients wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. c. hippocampus. b. occipital lobe. d. hypothalamus.

c. hippocampus. The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

18. A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

19. A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

d. Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurses most therapeutic response. a. Are you taking your medications the way they are prescribed? b. This loss is harder to accept because of your mental illness. Do you think you should be hospitalized? c. Im worried about how much you are crying. Your grief over your husbands death has gone on too long. d. The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings.

d. The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings. The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

26. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenagers grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school.

d. create a scholarship fund at their child's high school. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the childs parents have adapted to their loss? The parents: a. visit their childs grave daily. b. maintain their childs room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

d. throw flowers on the lake at each anniversary date of the accident. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.