Assessment
A 4 year old is referred to the outpatient mental health clinic after being in a severe car accident during which the child mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, “It’s my fault because I’m bad.” What trauma induced disorder does this data support?
A. Adjustment disorder
B. Dissociative identity disorder
C. Posttraumatic stress disorder (PTSD)
D. Acute stress disorder (ASD)
C. 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)
Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks?
A. Ineffective coping
B. Post-trauma syndrome
C. Complicated grieving
D. Panic anxiety
ANS: B
Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress disorder.
When planning the care of a client who is experiencing post-traumatic stress disorder, the nurse identifies which of the following as an appropriate goal? The client will report:
A. A decrease in flashbacks and nightmares.
B. Spending less time on ritualistic behavior.
C. A decrease in hearing voices.
D. Having more energy.
A (The target clinical manifestation for a client with post-traumatic stress disorder is flashbacks. Ritualistic behavior is associated with obsessive-compulsive disorder. Having a decreased energy level is associated with depression. Hearing voices is associated with schizophrenia.)
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need?
A. Teach deep breathing relaxation exercises
B. Place the client in a Trendelenburg position
C. Stay with the client and offer reassurance of safety
D. Administer the ordered prn buspirone (BuSpar)
ANS: C
The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life and the presence of a trusted individual provides assurance of personal safety.
When screening families for post-traumatic stress disorder following a major natural disaster, psychiatric and mental health nurses are practicing which type of disease prevention?
A. Primary.
B. Secondary.
C. Tertiary.
D. Universal.
B. Secondary
When discussing the symptoms of post-traumatic stress disorder (PTSD), the nurse should make which statement?
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. None of the other statements correctly describe the symptoms of PTSD.
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. None of the other options are characteristic of PTSD in a young child.
A nurse at Nurseslabs Medical Center is developing a care plan for a female client with post-traumatic stress disorder. Which of the following would she do initially?
A. Instruct the client to use distraction techniques to cope with flashbacks.
B. Encourage the client to put the past in proper perspective.
C. Encourage the client to verbalize thoughts and feelings about the trauma.
D. Avoid discussing the traumatic event with client.
C (Planning care for a client with post-traumatic stress disorder would involve helping the client to verbalize thoughts and feelings about the trauma. This will help the client work through the strong emotions connected with the trauma and, therefore foster the belief that she is able to cope. Avoiding discussion and using distraction techniques would be inappropriate. Option B may be possible later, after the client is able to verbalize strong emotions.)
After being robbed and beaten by an unknown assailant, a patient is diagnosed with post-traumatic stress disorder (PTSD). When developing a plan of care for the patient, which of these interventions will the healthcare provider plan to implement first?
A. Assist the patient in recalling the details of the event
B. Teach the patient coping skills to deal with anxiety
C. Promote the establishment of a trusting relationship
D. Ensure the patient is taking medications as prescribed
C. Promoting a trusting relationship is the priority of these options.
A client diagnosed with posttraumatic stress disorder is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of posttraumatic stress disorder was effective?
A. “I understand that the event I experienced, and how I deal with it, and my support system, all affect my disease process.”
B. “I have learned to avoid stressful situations as a way to decrease emotional pain.”
C. “So, natural opioid release during the trauma caused my body to become ‘addicted.’”
D. “Because of the trauma, I have a negative perception of the world and feel hopeless."
A. “I understand that the event I experienced, and how I deal with it, and my support system, all affect my disease process.” When the client verbalizes understanding of how the experienced event, individual traits, and available support systems affect his or her diagnosis, the client demonstrates a good understanding of the psychosocial cause of posttraumatic stress disorder (PTSD).
Option B: Avoiding situations as a way to decrease emotional pain is an example of a learned, not psychosocial, cause of PTSD.
Option C: The release of natural opioids during a traumatic event is an example of a biological, not psychosocial, cause of PTSD.
Option D: Having a negative perception of the world because of a traumatic event is an example of a cognitive, not psychosocial, cause of PTSD.
A group of community nurses sees and plans care for various clients with different types of problems. Which of the following clients would they consider the most vulnerable to post-traumatic stress disorder?
A. An 8 year-old boy with asthma who has recently failed a grade in school
B. A 20 year-old college student with DM who experienced date rape
C. A 40 year-old widower who has recently lost his wife to cancer
D. A wife of an individual with a severe substance abuse problem
B (Post-traumatic stress disorder is caused by the the experience of severe, specific trauma. Rape is a severely traumatic event. Although the situations in options A, C, and D are certainly stressful, they are not at the level of severe trauma)
A group of community nurses sees and plans care for various clients with different types of problems. Which of the following clients would they consider the most vulnerable to post-traumatic stress disorder?
A. An 8 year-old boy with asthma who has recently failed a grade in school
B. A 20 year-old college student with DM who experienced date rape
C. A 40 year-old widower who has recently lost his wife to cancer
D. A wife of an individual with a severe substance abuse problem
B. A 20 year-old college student with DM who experienced date rape.Post-traumatic stress disorder is caused by the the experience of severe, specific trauma. Rape is a severely traumatic event. Although the situations in options A, C, and D are certainly stressful, they are not at the level of severe trauma.
The nurse is talking with a client who just had a beautiful bouquet of roses delivered. Suddenly the client becomes tearful and stares out the window. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client?
A.Tell the client that the sexual abuse was in the past
B. Tell the client to relax and enjoy the roses
C. Assess if the client is having a flashback
D. Give the client some alone time and return later
C (Clients who have experienced a traumatic event such as sexual abuse may experience flashbacks. The triggers for these flashbacks may be visual, auditory, tactile, or olfactory.)
During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events?
A. Avoidance of stress is an important goal for living.
B. Control over one’s response to stress is possible.
C. Most people have no control over their level of stress.
D. Significant others are important to provide care and concern.
B. Control over one’s response to stress is possible. When learning to manage stress, clients find it helpful to believe that they have the ability to control their response to it. It is impossible to avoid stress, which is a normal life experience. Stress can be positive and growth enhancing as well as harmful. The belief that one has some control is the significant factor in minimizing stress response.
A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next?
A. Beta blocker
B. Barbiturate
C. Tricyclic antidepressant (TCA)
D. Sedative
C. Tricyclic antidepressant (TCA)
TCAs or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. None of the other options would be the next consideration.
Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD?
Select all that apply.
1. Visiting the scene of the accident over and over
2. Talking with strangers about the events of the accident
3. Flashbacks of the accident
4. Hypervigilance
5. Irritability
6. Difficulty concentrating
7. Mania
3. Flashbacks of the accident, 4. Hypervigilance, 5. Irritability, 7. Mania
All these symptoms are signs of PTSD. The other options are not associated with signs of PTSD. Cognitive Level: Understand (Comprehension)
A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.)
A. The client has experienced symptoms of the disorder for 2 weeks.
B. The client fears a physical integrity threat to self.
C. The client feels detached and estranged from others.
D. The client experiences fear and helplessness.
E. The client is lethargic and somnolent.
ANS: B, C, D
Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.
A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care?
A. The client will have no flashbacks.
B. The client will be able to feel a full range of emotions by discharge.
C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
D. The client will refrain from discussing the traumatic event.
ANS: C
The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.
A client diagnosed with post-traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that warrant the need for this medication?
A. Flat affect and anhedonia
B. Persistent anorexia and 10 lb weight loss in 3 weeks
C. Flashbacks of killing the enemy
D. Distant and guarded relationships
ANS: C
The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone (Invega). Paliperidone is an antipsychotic medication that can be used to treat the psychotic symptom of flashbacks.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
A. "I will need scheduled blood work in order to monitor for toxic levels of this drug."
B. "I won't stop taking this medication abruptly because there could be serious complications."
C. "I will not drink alcohol while taking this medication."
D. "I won't take extra doses of this drug because I can become addicted."
ANS: A
The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.