Dissociative and Sexual and Gender Identity disorders

Which statement supports a psychodynamic theory in the etiology of dissociative

disorders?

1. Dysfunction in the hippocampus affects memory.

2. Dissociate reactions may be precipitated by excessive cortical arousal.

3. Coping capacity is overwhelmed by a set of traumatic experiences.

4. Repression is used as a way to protect the client from emotional pain.

4. Dissociative behaviors occur when individ-

uals repress distressing mental contents

from conscious awareness. The repression

of mental contents is perceived as a coping

mechanism for protecting the client from

emotional pain that has arisen from dis-

turbing external circumstances or anxiety-

provoking internal urges and feelings.

This supports a psychodynamic theory in

the etiology of dissociative disorders.

A frightened client diagnosed with dissociative fugue tells the nurse, “I don’t know

where I am or how I got here. What is wrong with me?” Which nursing response

reflects a neurobiological perspective?

1. “You appear to have repressed distressing feelings from your conscious awareness.”

2. “Sometimes these symptoms are found in individuals with temporal lobe epilepsy or

severe migraine headaches.”

3. “When individuals have experienced some sort of trauma, the primary self needs to

escape from reality.”

4. “It has been found that these symptoms are seen more often when first-degree rela-

tives have similar symptoms.”

2. Some clinicians have suggested a possible

correlation between neurological alter-

ations and dissociative disorders. This

nurse’s response relates the relationship

between temporal lobe epilepsy or severe

migraine headaches or both to the diagno-

sis of dissociative fugue and is from a neu-

robiological perspective.

Various biological and psychosocial theories have been proposed regarding homosexu-

ality. Which etiological factor has emerged consistently?

1. Homosexual behavior is an individual preference.

2. Homosexual behavior is the result of negative Oedipal position.

3. Homosexual behavior is based on the orientation of the individual.

4. Homosexual behavior has no definitive etiological evidence supporting either

biologic or psychosocial theories.

4. No one knows for sure why individuals

become homosexual or heterosexual.

Various theories have been proposed

regarding the issue, but no single etiologi-

cal factor has emerged consistently. Many

contributing factors likely influence the

development of sexual orientation.

Which would the nurse expect to assess in a client diagnosed with fetishism?

1. History of exposing genitalia to strangers.

2. History of sexually arousing fantasies involving nonliving objects.

3. History of urges to touch and rub against nonconsenting individuals.

4. History of fantasies involving the act of being humiliated, beaten, or bound.

2. Fetishism involves recurrent, intense,

sexual urges or behaviors, of at least

6 months in duration, involving the use of

nonliving objects. The sexual focus is

commonly on objects intimately associat-

ed with the human body (e.g., shoes,

gloves, or stockings).

A client admitted with dissociative fugue is being evaluated. Which assessment infor-

mation would indicate that the client is ready for discharge?

1. The client is able to maintain reality during stressful situations.

2. The client is able to verbalize why the personalities exist.

3. The client is able to discuss feelings such as depersonalization.

4. The client is able to integrate subpersonalities into a whole personality.

1. Because stress is the underlying cause of

dissociative fugue, the client’s ability to

maintain reality during stressful situations

would indicate that the client meets dis-

charge criteria.

A client is diagnosed with male orgasmic disorder. Which assessed behavior supports

this diagnosis?

1. Inability to maintain an erection.

2. A delay in or absence of ejaculation following normal sexual excitement.

3. Premature ejaculation.

4. Dyspareunia.

2. Male orgasmic disorder is characterized

by persistent or recurrent delay in, or

absence of, orgasm following a normal

sexual excitement phase during sexual

activity, which the clinician, taking into

account the person’s age, judges to be

adequate in focus, intensity, and duration.

A client who is self-identified as homosexual is discussing sexual orientation. Which

client statement is true as it relates to this concept?

1. “The psychiatric community does not consider consensual homosexuality to be a

mental disturbance.”

2. “Homosexuality is described on Axis I of the DSM-IV-TR.”

3. “Homosexuality is considered deviant behavior, and I will need therapeutic counseling.”

4. “Altered levels of testosterone affect the diagnosis of homosexuality and must be cor-

rected to deal with the symptoms of this disorder.”

1. The psychiatric community does not con-

sider consensual homosexuality to be a

mental disturbance. The concept of

homosexuality as a disturbance in sexual

orientation no longer appears in the

DSM. Instead, the DSM-IV-TR is con-

cerned only with the individual who expe-

riences “persistent and marked distress

about his or her sexual orientation.”

Which client situation supports a potential diagnosis of a dissociative fugue?

1. A client enters the emergency department in New York City without understanding

who he or she is or how he or she got there.

2. A client known as being shy and passive comes into the emergency department angry

and demanding.

3. A client brought to the emergency department after a car accident is unable to recall

his or her address or phone number.

4. A client seen in the emergency department complains of feeling detached from the

current situation.

1. The characteristic feature of dissociative

fugue is the inability to recall some or all of

one’s past. This is usually precipitated by

severe, psychosocial stress. A situation in

which a client has no idea who he or she is

or how he or she arrived is an example of

symptoms experienced during dissociative

fugue.

A 65-year-old woman with a history of prostitution is seen in the emergency depart-

ment experiencing a recent onset of auditory hallucinations and bizarre behaviors.

Which diagnosis would the nurse expect to document?

1. Schizophrenia.

2. Tertiary syphilis.

3. Gonorrhea.

4. Schizotypal personality disorder.

2. One of the symptoms of the tertiary stage

of syphilis is insanity. The client’s symp-

toms of auditory hallucinations and

bizarre behaviors would be reflective of

this diagnosis. Although there can be

other reasons for these symptoms, the

client’s history of prostitution and recent

onset of symptoms would warrant investi-

gation into the possible diagnosis of terti-

ary syphilis.

A client diagnosed with depersonalization disorder has a short-term outcome that

states, “The client will verbalize an alternate way of dealing with stress by day 4.”

Which nursing diagnosis reflects the problem that this outcome addresses?

1. Disturbed sensory perception R/T severe psychological stress.

2. Ineffective coping R/T overwhelming anxiety.

3. Self-esteem disturbance R/T dissociative events.

4. Anxiety R/T repressed traumatic events.

2. The outcome of verbalizing alternate ways

of dealing with stress would apply to the

nursing diagnosis of ineffective coping

R/T overwhelming anxiety.

A client diagnosed with dissociative identity disorder has been hospitalized for 7 days.

The client has a nursing diagnosis of ineffective coping R/T repressed severe anxiety.

Which outcome would be appropriate?

1. The client will recover deficits in memory by day 14.

2. The client will verbalize awareness of multiple personalities and the reason for their

existence by day 14.

3. The client will demonstrate the ability to perceive stimuli accurately.

4. The client will demonstrate one adaptive way to deal with stressful situations by

day 14.

4. A client diagnosed with dissociative iden-

tity disorder is coping with stressful situa-

tions by self-dissociation into multiple

personalities. The client’s being able to

demonstrate adaptive coping mechanisms

in dealing with stress reflects a positive

outcome for the nursing diagnosis of inef-

fective coping.

A client newly admitted to an in-patient psychiatric unit has a diagnosis of pedophilia.

When working with this client, which would be the nurse’s initial action?

1. Assess the part of the sexual response cycle in which the disturbance occurs.

2. Evaluate the nurse’s feelings regarding working with the client.

3. Establish a therapeutic nurse-client relationship.

4. Explore the developmental alterations associated with pedophilia.

2. When working with clients diagnosed

with pedophilia, the nurse’s initial action

should be to evaluate personal feelings.

Personal feelings, attitudes, and values

should not interfere with acceptance of

the client. The nurse must remain non-

judgmental.

A client diagnosed with exhibitionism is newly admitted to an in-patient psychiatric

unit. Which would be an example of a behavioral nursing intervention for this client?

1. Encourage the client to pair noxious stimuli with sexually deviant impulses.

2. Help the client identify unresolved conflicts and traumas from early childhood.

3. Administer prescribed medications that block or decrease circulating androgens.

4. Administer prescribed progestin derivatives to decrease the client’s libido.

1. Aversion therapy is a behavioral nursing

intervention that encourages the pairing

of noxious stimuli, such as bad odors,

with deviant sexual impulses in an

attempt to assist the client to avoid inap-

propriate behavior. This behavioral

approach is used in the treatment of

clients diagnosed with paraphilias such as

exhibitionism.

A newly admitted client is diagnosed with dissociative identity disorder. Which nurs-

ing intervention is a priority?

1. Establish an atmosphere of safety and security.

2. Identify relationships among subpersonalities and work with each equally.

3. Teach new coping skills to replace dissociative behaviors.

4. Process events associated with the origins of the disorder.

1. A growing body of evidence points to the

etiology of dissociative identity disorder as

a set of traumatic experiences that over-

whelms the individual’s capacity to cope

by any means other than dissociation. It is

a priority for the nurse to establish an

atmosphere of safety and security in

which trust can be established. Trust must

be established before a client would feel

comfortable to discuss highly charged,

past traumatic events.

A newly admitted client diagnosed with depersonalization disorder has a nursing diag-

nosis of anxiety R/T family stressors. Which nursing intervention would be most help-

ful in building a trusting nurse-client relationship?

1. Identify stressors that increase anxiety levels.

2. Encourage use of adaptive coping mechanisms to decrease stress.

3. Discuss events surrounding episodes of depersonalization.

4. Reassure the client of safety and security during periods of anxiety.

4. For the nurse to build a trusting nurse-

client relationship, the nurse must assure

the client of safety and security during

periods of anxiety. When safety has been

established, other interventions may be

implemented.

The nursing student is learning about the sexual disorder of paraphilia. Which student

statement indicates that learning has occurred?

1. “The term ‘paraphilia’ is used to identify repetitive or preferred sexual fantasies or

behaviors.”

2. “Individuals diagnosed with a paraphilia experience extreme personal distress and

frequently seek treatment.”

3. “Oral-genital, anal, homosexual, and sexual contact with animals is currently viewed

as paraphilia.”

4. “Most individuals with a paraphilia are women, and more than 50% of these individ-

uals have onset of their paraphilic arousal after age 18.”

1. The term “paraphilia” is used to identify

repetitive or preferred sexual fantasies

or behaviors that involve any of the fol-

lowing: the preference for use of nonhu-

man objects, repetitive sexual activity

with humans that involves real or simu-

lated suffering or humiliation, or repeti-

tive sexual activity with nonconsenting

partners.

The nursing student is learning about depersonalization disorder. Which student state-

ment indicates that learning has occurred?

1. “Depersonalization disorder has an alteration in the perception of the external envi-

ronment.”

2. “The symptoms of depersonalization are rare, and few adults experience transient

episodes.”

3. “Depersonalization disorder is characterized by temporary change in the quality of

self-awareness.”

4. “The alterations in perceptions are experienced as relaxing and are rarely accompa-

nied by other symptoms.”

3. Clients diagnosed with depersonalization

disorder experience temporary changes in

the quality of self-awareness. These

changes may include feelings of unreality,

changes in body image, feelings of detach-

ment from the environment, or a sense of

observing oneself from outside the body.

A client diagnosed with dissociative identity disorder attributed to childhood sexual

abuse has an outcome that states, “The client will verbalize causative factors for the

development of multiple personalities.” Which charting entry would support a success-

ful evaluation of this outcome?

1. “Able to state the particular function of each of the different personalities.”

2. “Discussed history of childhood sexual abuse.”

3. “Was able to be redirected to topic at hand during group therapy.”

4. “Verbalizes understanding that treatment may be lengthy.”

2. Research has shown that the etiology of

DID is usually based on a long history of

childhood physical or sexual abuse or

both. Discussing a past history of sexual

abuse would connect these traumatic

events to the reason why the client’s mul-

tiple personalities exist and would support

a successful outcome.

Which of the following nursing evaluations for a hospitalized client diagnosed with dis-

sociative identity disorder would lead the treatment team to consider discharge? Select

all that apply.

1. The client is able to recall events associated with a traumatic or stressful situation.

2. The client is able to communicate increased levels of anxiety before dissociation

occurs.

3. The client is able to demonstrate more adaptive coping strategies to avert dissocia-

tive behaviors.

4. The client is able to verbalize the existence of multiple personalities and the purpos-

es they serve.

5. The client demonstrates continued use of alternate personalities to deal with stress-

ful situations.

1. Being able to recall traumatic or stressful

events is the first step in dealing with

stressors, which are the underlying cause

of the client’s dissociative identity disor-

der (DID). Because of this client’s insight,

the treatment team may consider this

client for discharge to an out-patient

treatment center.

2. Being able to communicate increased

levels of anxiety before dissociation is a

major step toward the client’s connecting

the increased anxiety to the occurrence of

dissociation. Because of this client’s

insight, the treatment team may consider

this client for discharge to an out-patient

treatment center.

3. Being able to employ adaptive coping

mechanisms indicates that the client is

developing appropriate strategies to avoid

dissociation. Because of this newly

acquired ability, the treatment team may

consider this client for discharge to an

out-patient treatment center.

4. Being able to verbalize the existence of

multiple personalities and the purposes

they serve indicates insight into the

underlying disease process. Because of

this client’s insight, the treatment team

may consider this client for discharge to

an out-patient treatment center.

A client is diagnosed with a sexual aversion disorder. A nursing diagnosis of sexual dys-

function is documented for this client. Which behavior indicates successful resolution

of this client’s problem?

1. Client resumes sexual activities at a level satisfactory to self and partner.

2. Client expresses satisfaction with own sexual patterns.

3. The client’s deviant sexual behaviors have decreased.

4. The client accepts homosexual drives as normal sexual functioning.

1. A client’s resuming sexual activities at a

level satisfactory to self and partner indi-

cates successful resolution of the client’s

sexual dysfunction problem. Sexual dys-

function is defined as the state in which

an individual experiences a change in sex-

ual function that is viewed as unsatisfying,

unrewarding, or inadequate.