Chapter 28: Trauma- and Stressor-Related Disorders

1. The nurse includes information regarding methods to enhance sleep for a client who experiences insomnia due to posttraumatic stress disorder (PTSD). Which client statement indicates a need for additional teaching regarding sleep hygiene?

a) "I will maintain the same sleep schedule 7 days a week"

b) "I have found that drinking a glass or two of wine every night helps me to fall asleep"

c) "I will avoid taking naps during the day"

d) "I will avoid caffeinated beverages during the late afternoon and early evening hours"

b) "I have found that drinking a glass or two of wine every night helps me to fall asleep"

Pg.

2. 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?

a) Concerns for the client's safety have caused the client to change daily routines

b) Complementary and alternative therapies have failed to resolve the client's anxiety

c) The attack was an isolated, rather than ongoing, event

d) The attack took place several months ago, and the client's anxiety has been continuous

d) The attack took place several months ago, and the client's anxiety has been continuous

Pg.

3. When presenting a discussion of posttraumatic stress disorder (PTSD) to a group of emergency department nurses, the psychiatric-mental health nurse provides examples of traumatic events that may precede PTSD. Which example would the nurse most likely include? Select all that apply.

a) Surviving an EF 4 tornado

b) Personal assault by a family member

c) Military combat mission where there were casualties

c) Urinary incontinence due to a prolapsed bladder

e) Falling off a playground swing

a) Surviving an EF 4 tornado

b) Personal assault by a family member

c) Military combat mission where there were casualties

Pg.

4. When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing which condition?

a) Paranoia

b) Emotional numbness

c) Dissociative amnesia

d) Posttraumatic stress disorder

d) Posttraumatic stress disorder

Pg. 528

When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing posttraumatic stress disorder, not emotional numbness, dissociative amnesia, or paranoia.

5. The nurse is providing care for a client whose history of intimate partner violence has resulted in posttraumatic stress disorder (PTSD). The client has few friends and states that the client is estranged from the client's family. How can the nurse best enhance the client's social support?

a) Facilitate the client's participation in a support group

b) Encourage the client to make new friends

c) Facilitate a meeting between the client and the client's family members

d) Provide the client with educational resources that promote the client's self-worth

a) Facilitate the client's participation in a support group

Pg. 524

A support group can be a valuable source of social support. If the client states that the client is estranged from the client's family, it would be inappropriate for the nurse to independently broach this barrier. Making new friends is difficult for a client experiencing PTSD. Educational resources can be valuable but are not a substitute for social support.

6. A psychiatric-mental health nurse is conducting a program for family members of clients diagnosed with posttraumatic stress disorder. When describing the concept of resilience, which information would the nurse most likely include? Select all that apply.

a) The greater a person's resilience, the less likely the individual will develop maladaptive behaviors

b) Everyone who experiences a traumatic event can develop resilience

c) When someone is feeling out of control in life, resilience is diminished

d) As a person's positive self-concept increases, resilience also increases over time

e) Those with a supportive family are more likely to develop resilience than those without a supportive family

a) The greater a person's resilience, the less likely the individual will develop maladaptive behaviors

d) As a person's positive self-concept increases, resilience also increases over time

Pg.

7. 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?

a) Complicated grieving

b) Impaired social interaction

c) Defensive coping

d) Ineffective impulse control

d) Ineffective impulse control

Pg. 526

This client is acknowledging that he or she is unable to manage the behaviors surrounding alcohol abuse. This is not necessarily a form of defensive coping, though it is certainly an unhealthy coping strategy. Grieving is more closely related to death and loss than PTSD. Problems with social interaction are not at the essence of the client's statement.

8. A client with post-traumatic stress disorder has just been prescribed sertraline. When teaching the client about this medication, which information would the nurse most likely stress?

a) Taking the medication once per day

b) Taking the medication one hour before a meal or two hours after a meal

c) Notifying the provider to change to sublingual administration in the event of stomach upset

d) Seeking medical assistance for any change in appetite

a) Taking the medication once per day

Pg. 524

Sustained serotonin reuptake inhibitors are taken once daily, due to their long half-life. A change in appetite does not necessarily warrant medical intervention, depending on the severity. SSRIs are only administered orally and can be taken with or without food.

9. What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?

a) The client states that usual coping mechanisms are ineffective

b) The client states that the client's mood is "alright" when appearing to be in some distress

c) The client experiences awakenings during the night and is unable to fall asleep again

d) The client is often "staring into space" and has no idea how much time has passed

d) The client is often "staring into space" and has no idea how much time has passed

Pg. 516

"Spacing out" is an example of dissociation (depersonalization). It is not uncommon for the client with PTSD to experience failure of coping skills, sleep disturbances, and reluctance to acknowledge moods, but these are not evidences of dissociation.

10. A psychiatric nurse is assessing a client with post-traumatic stress disorder (PTSD). During the psychosocial component of the assessment, what assessment question should the nurse include?

a) "Have you been having any side effects from your medication?"

b) "Do you feel like treatment has been beneficial so far?"

c) "How are your symptoms affecting your day-to-day routines?"

d) "How would describe the quality of your sleep these days?"

c) "How are your symptoms affecting your day-to-day routines?"

Pg. 521

Assessing the effect of a client's PTSD on his or her daily routines is a major focus of psychosocial assessment. Sleep is a component of a physical assessment, as are medication side effects. Eliciting the client's opinion of treatment so far is important, but this is not situated solely within the psychosocial domain.

11. Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?

a) The risk of developing PTSD following leukemia treatment is about the same as all children of the same age

b) In a family unit where one child is diagnosed with cancer, all the children in the household are at increased risk for developing PTSD

c) Children who were abused during childhood are more likely to be diagnosed with obsessive-compulsive disorder rather than PTSD

d) Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse

d) Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse

Pg. 517

For adolescents, PTSD has been associated with an increased risk of drug use. Childhood cancer survivors have been found to have four times the risk of developing PTSD as their siblings. In another study of childhood cancer survivors, nearly 16% had PTSD. Similarly, high rates of PTSD have been reported among clients with alcohol and drug dependence who experienced childhood abuse.

12. When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

a) Failure to integrate identity, memory, and consciousness

b) Total amnesia of the events that caused the disorder

c) Overuse of sedatives like alcohol

d) Disinhibited social engagement, being overly friendly with strangers

a) Failure to integrate identity, memory, and consciousness

Pg. 528

The essential feature of these disorders involves a failure to integrate identity, memory, and consciousness. That is, unwanted intrusive thoughts disrupt one's contact with the here and now, or memories that are normally accessible are lost. These disorders are closely related to trauma- and stressor-related disorders but are categorized separately.

13. A client with posttraumatic stress disorder (PTSD) has begun to stay out late every night and "party" with their friends. When family members ask about when the client is going to return to work, they become extremely irritated and verbal lashes out, saying some very hurtful things. The priority NANDA for this client would be which of the following?

a) Anxiety

b) Ineffective activity planning

c) Risk of relocation stress syndrome

d) Ineffective impulse control

d) Ineffective impulse control

Pg. 526-527

Depending on the trauma, posttrauma syndrome, rape trauma syndrome, risk for suicide, anxiety, defensive coping, hopelessness, ineffective impulse control, and powerlessness are examples of nursing diagnoses generated by assessment of a client with PTSD.

14. One major difference between posttraumatic stress disorder (PTSD) and the other anxiety disorders is that...

a) Symptoms begin after exposure to a traumatic stressor

b) The person experiences acute anxiety with feelings of panic

c) The person has physiological reactions, not just psychological ones

d) Prozac usually works best with PTSD

a) Symptoms begin after exposure to a traumatic stressor

Pg. 528

There is an easily identifiable stressful event preceding the onset of PTSD symptoms. When symptoms of ASD continue for more than 1 month and are accompanied by functional impairment or stress, the diagnosis changes to acute posttraumatic stress disorder (PTSD). Symptoms include generalized anxiety, intrusive thoughts or images of the trauma, flashbacks, nightmares, and other sleep disturbances.

15. A client with posttraumatic stress disorder (PTSD) suffered injuries in a workplace fire several months ago and now admits that the client is reluctant to join family members on a camping trip. The client states, "The last place I want to be is sitting around a bonfire, pretending to have a good time." The nurse should recognize the characteristics of:

a) Avoidance

b) Depersonalization

c) Derealization

d) Numbing

a) Avoidance

Pg. 516

The client's reluctance to be around a fire is a clear example of avoiding reminders of a trauma. This avoidance is not an example of numbing, derealization (feelings of unreality), or depersonalization.

16. A client who has been diagnosed with post-traumatic stress disorder is scheduled to begin stress inoculation training. The nurse should document what desired outcome related to this therapy?

a) The client will express a willingness to visit the site of the trauma

b) The client will acknowledge his diagnosis to family and close friends

c) The client will use benzodiazepines and SSRIs safely

d) The client will demonstrate anxiety-reduction strategies

d) The client will demonstrate anxiety-reduction strategies

Pg. 519

Stress inoculation therapy aims to instill strategies for reducing anxiety. A willingness to visit the site of the trauma would be an indirect outcome. Acknowledging a diagnosis is important, but is not directly related to stress inoculation therapy and the focus on anxiety management. Medications are unrelated to stress inoculation therapy.

17. Which individual is most likely to be diagnosed with posttraumatic stress disorder (PTSD)?

a) A teenage boy who has begun to be the object of bullying inside and outside the classroom

b) A 12-year-old girl who has recently moved cross-country and desperately misses her old friends

c) A middle-aged woman with a history of anxiety who suffered a random physical assault

d) An adult male client who has been admitted to the hospital three times for complications of surgery

c) A middle-aged woman with a history of anxiety who suffered a random physical assault

Pg. 515

Woman are twice as likely as men to develop PTSD, and a history of anxiety is a known risk factor. Physical assault is among the most common precursors to PTSD. Each of the other listed individuals is facing a crisis that has the potential to result in trauma, but none has the same constellation of risk factors as the middle-aged woman.

18. A nurse is interviewing a client with suspected posttraumatic stress disorder (PTSD). Which finding would the nurse most likely assess as supporting this suspicion? Select all that apply.

a) Describes avoiding people and places arousing painful memories

b) Experiences sympathetic nervous system symptoms suggestive of a heart attack

c) Reports feelings of being detached or empty inside

d) Reports the experience of flashbacks

e) Feels driven to repeat behaviors

f) Demonstrates hypervigilant behavior

a) Describes avoiding people and places arousing painful memories

c) Reports feelings of being detached or empty inside

d) Reports the experience of flashbacks

f) Demonstrates hypervigilant behavior

Pg. 515

A person with PTSD persistently reexperiences the trauma through memories, dreams, flashbacks, or reactions to external cues about the event and therefore avoids stimuli associated with the trauma. The person feels a numbing of general responsiveness and shows persistent signs of increased arousal such as insomnia, hyperarousal or hypervigilance, irritability, or angry outbursts. He or she reports losing a sense of connection and control over his or her life. This can lead to avoidance behavior, or trying to avoid any places or people or situations that may trigger memories of the trauma. Repeating behaviors indicates an obsessive compulsion and the sympathetic response aligns with panic attacks.

19. A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline?

a) The nurse should avoid touching the client during interactions unless necessary

b) The nurse should encourage the client to use progressive relaxation techniques rather than prescribed medications

c) The nurse should ensure that a colleague is present when the client is assessed

d) The nurse should encourage limiting contact with friends and family until the client's mood improves

a) The nurse should avoid touching the client during interactions unless necessary

Pg. 526

The nurse should use touch with great caution when working with a client who has experienced a sexual assault. There is no clear need for two caregivers to be present during an assessment. If medications have been prescribed, the nurse should never encourage the client to not take them. The client's support network should be accessed as much as possible.

20. The nurse is assessing a client who was sexually assaulted several months ago and who has subsequently developed posttraumatic stress disorder (PTSD). The nurse observes that the client's nonverbals are closed and the client is reluctant to engage with the nurse. How should the nurse best interpret this client's behavior?

a) The client has likely had a series of negative interactions with health providers

b) The client's PTSD is affecting the client's cognition and information processing

c) The client's trauma likely has an impact on the client's ability to trust

d) The client has likely responded poorly to prior treatments

c) The client's trauma likely has an impact on the client's ability to trust

Pg. 519-520

Persons whose trauma resulted from sexual assault are likely to be reluctant to trust. It is possible that the client has had negative encounters with health care providers, but issues related to trust are more likely, given the nature of the client's trauma. Cognitive deficits are less likely, and mistrust is not necessarily indicative that treatment is ineffective.

21. The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

a) Organize a family meeting where family members can tell the client how they feel

b) Educate the family about the usual emotional responses to returning home from military service

c) Assess the client for signs and symptoms associated with post-traumatic stress disorder

d) Educate the family about the relationship between hyperarousal and emotional distance

c) Assess the client for signs and symptoms associated with post-traumatic stress disorder

Pg. 515

It is highly plausible that the client has post-traumatic stress disorder, given the high incidence and prevalence among veterans. Assessment should precede any interventions such as family meetings or education sessions.

22. A client who is a bus driver was involved in an accident in which two of her passengers died. The client blames herself for their death even though she was exonerated in the follow-up investigation. To help the client see the event more realistically, the nurse should:

a) Discuss the possibility of benzodiazepines with the primary care provider

b) Arrange for the client to receive eye movement, desensitization, and reprocessing (EMDR) therapy

c) Facilitate a referral for cognitive restructuring therapy

d) Discuss the possibility of SSRIs with the primary care provider

c) Facilitate a referral for cognitive restructuring therapy

Pg. 519

Cognitive restructuring aims to help the client reframe an event in a more realistic way. EMDR addresses the emotional impact of the events. Medications aid with anxiety and mood but do not directly change the client's view of events.

23. A client with posttraumatic stress disorder (PTSD) has been unable to have restful sleep since being the victim of a robbery and assault. What should the nurse recommend?

a) Adopting later times for going to bed and waking up

b) Temporarily moving to a new bedroom, if possible

c) Limiting naps to times earlier than 3:00 p.m.

d) Exercising regularly, but not close to bedtime

d) Exercising regularly, but not close to bedtime

Pg. 520

Exercise enhances sleep, but the hours within 3 hours of bedtime should be avoided. Naps should be avoided completely. Choosing new bedtimes and a new bedroom are not actions that are noted to improve sleep hygiene.

24. 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?

a) Anxiety related to illusions

b) Sleep pattern disturbance related to recurrent nightmares

c) Ego disintegration related to severe anxiety

d) Unrealistic fear of fire related to conversion reaction

b) Sleep pattern disturbance related to recurrent nightmares

Pg. 520

The appropriate nursing diagnosis is sleep pattern disturbance. The client is not having illusions, nor is the client's fear of the fire unrealistic. The client is not experiencing ego disintegration.

25. The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should:

a) Corroborate the client's statements with a trusted friend or family member

b) Prioritize psychological findings over physical findings

c) Try to identify any strengths or skills that can be applied during recovery

d) Reassure the client that the client will eventually have a full recovery

c) Try to identify any strengths or skills that can be applied during recovery

Pg. 521

During assessment, it is important to note any strengths that can be integrated into the client's care. Psychological findings do not always take priority over physical findings and it is unnecessary to confirm everything that the client says with another individual. The nurse must avoid false reassurance; full recovery is never guaranteed.

26. 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) A critical examination of the ways the client's PTSD has affected the client's life

b) A family meeting where each member will describe the effects of the client's PTSD

c) A visit with the therapist to the place where the explosion occurred

d) A visit to a support group created for victims of the tragedy

c) A visit with the therapist to the place where the explosion occurred

Pg. 519

Exposure therapy may involve a visit to the place where a traumatic event occurred. Reflection, family meetings, and support groups may be components of the client's broader treatment plan, but they are not exposure therapy.

27. A group of at-risk teenagers have successfully completed an outdoor training program in which they had to collaborate and conquer a number of challenges. The nurse should identify what likely outcome of this program?

a) Decreased risk for personality disorders

b) Decreased risk for somatic symptom disorders

c) Hyperarousal and enhanced coping for participants

d) Enhanced resilience for the participants

d) Enhanced resilience for the participants

Pg. 514

Facing and conquering challenges increases self-worth, self-efficacy, and resilience. This type of activity is unlikely to have a direct effect on participants' risks of somatic symptom disorders or personality disorders, which have complex etiologies. Participants' coping is likely to be enhanced, but hyperarousal is associated with poor coping and low resilience.

28. A client with posttraumatic stress disorder (PTSD) asks the nurse about this eye movement, desensitization, and reprocessing (EMDR) treatment. The nurse explains that this treatment:

a) Guides the client through images of the trauma, allowing for progressive desensitization

b) Blocks the trauma from appearing in the client's psychological frame using carefully placed electrical stimuli

c) Helps the client understand why recovering from the trauma is difficult and gives them new ways of coping

d) Takes a long time because you have to have counseling sessions a minimum of twice a week

a) Guides the client through images of the trauma, allowing for progressive desensitization

Pg. 518-519

EDMR is a process of reviewing and visualizing disturbing memories of traumatic or distressing experiences to reduce the long-term impact of the events. The client is guided through images of the trauma, allowing for progressive desensitization. Under deep relaxation, the client maintains an image of the traumatic event while focusing on the lateral movement of the clinician's finger. This recent approach has been successful in minimizing the fear response and avoidance pattern of those with PTSD. Counseling, blocking trauma via electrical stimuli, and using cognitive processing therapy are not a part of EDMR, but are separate possible treatment plans.

29. The nurse is interviewing a client who witnessed a fatal accident at the workplace and was unable to save a colleague. What assessment findings would support a diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply.

a) The client has nightmares about the accident

b) The client says the client's family describes the client now as "edgy" and "irritable"

c) The accident took place 2 weeks ago

d) The client says the client is "unable to face that place again"

e) Management is blaming the client for the accident

a) The client has nightmares about the accident

b) The client says the client's family describes the client now as "edgy" and "irritable"

d) The client says the client is "unable to face that place again"

Pg. 515

Diagnostic criteria for PTSD include avoidance of the site of the trauma, hyperarousal, and nightmares. However, the 2-week time period suggests a diagnosis of acute stress disorder rather than PTSD. The response of management is a stressor but is not among the diagnostic criteria.

30. A client has been diagnosed with posttraumatic stress disorder (PTSD) after a house fire. Which nursing intervention is most appropriate?

a) Focus on the client's hopes and plans for the future during interviews and other interactions

b) Help the client to explore complementary and alternative therapies to prevent dependence on medications

c) Arrange a consult with an occupational therapist to manage the client's return to work

d) Facilitate the client's introduction to a support group of other people recovering from PTSD

d) Facilitate the client's introduction to a support group of other people recovering from PTSD

Pg. 524

Support groups are known to benefit many clients with PTSD, and for most people this is more relevant than occupational therapy. PTSD often necessitates medication, but the medication classes that are used do not create a risk for dependence. Focusing on the future is appropriate in some interactions and at some points in the client's recovery, but there are many contexts where this would not be relevant or appropriate.

31. The nurse is interviewing a client who has been diagnosed with posttraumatic stress disorder (PTSD) after being randomly attacked with a gun. The client describes a recent event where the client panicked and jumped for cover when a car backfired on the street. How should the nurse best interpret this event?

a) The client temporarily dissociated with the traumatic event

b) The client is experiencing hyperarousal

c) The client experienced an episode of derealization

d) The client lacks effective coping strategies

b) The client is experiencing hyperarousal

Pg. 516

Hyperarousal causes individuals with PTSD to have a reduced threshold for stressful stimuli. This does not, however, indicate that the client necessarily has inadequate coping skills. Derealization and dissociation both involve a break with the reality of present circumstances.

32. 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?

a) Education to the client about appropriate social interactions

b) Frequent assessment for delusional thinking or hallucinations

c) Administration of monoamine oxidase inhibitors (MAOIs) as prescribed

d) Vigilant monitoring for potential indications of self-harm

d) Vigilant monitoring for potential indications of self-harm

Pg. 519

The risk for suicide or other forms of self-harm is high in clients with PTSD. MAOIs are not used to treat the disorder, and delusions and hallucinations rarely occur. Social isolation is common among patients with PTSD; inappropriate social interactions, however, are less common.

33. The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?

a) The client reports crying at unpredictable times

b) The client's family members describe the client as irritable and agitated

c) The client states that the client has been neglecting business in recent weeks

d) The client reports large gaps in memory of the traumatic event

d) The client reports large gaps in memory of the traumatic event

Pg. 516

Amnesia about traumatic events is characteristic of dissociation. Emotional lability, apathy, and agitation are not unusual in a client dealing with PTSD, but these do not directly indicate the presence of dissociation.

34. The nurse is working with a female client with a history of sexual abuse who has recently been diagnosed with post-traumatic stress disorder (PTSD). What characteristic of the abuse should the nurse recognize as the most significant contributor to the client's PTSD?

a) Some members of the extended family still refuse to acknowledge the abuse

b) The perpetrator was arrested and a very public trial followed

c) The assaults were perpetrated by a trusted uncle well-known in the community

d) The assaults began when the client was only 3 years old

d) The assaults began when the client was only 3 years old

Pg. 515

Sexual abuse at a young age is a particularly significant risk factor for PTSD. This aspect of the abuse is likely to be more significant than the fact that the abuser was well-known and publicly persecuted or that there are people outside the immediate family who do not acknowledge it.

35. 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 most warrants further assessment for posttraumatic stress disorder?

a) An adolescent who states "I've lost my soulmate" after the death of a boyfriend or girlfriend in an accident

b) An adolescent who began smoking in the weeks after discovering a dead body in a park

c) An adolescent who often redirects the conversation to the subject of the adolescent's sister's death

d) An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

d) An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

Pg. 515

Adolescents with PTSD may act out by engaging in disruptive behavior. The adolescent redirecting discussion to the dead sister and the adolescent who lost a relationship because of death from an accident are expressing uncomplicated grief. The adolescent who began smoking requires intervention but is not necessarily experiencing PTSD.

36. A client with post-traumatic stress disorder has recently been prescribed prazosin. What statement by the client would most clearly suggest that the medication is having the desired effect?

a) "My wife says that I'm a lot more emotionally available these days"

b) "I think that I'm being a lot more patient with my kids lately"

c) "I'm sleeping better than I have for many months"

d) "I haven't had any flashbacks since last week"

c) "I'm sleeping better than I have for many months"

Pg. 524

Prazosin is used to relieve the sleep disturbances and nightmares that accompany PTSD. It does not directly affect mood or flashbacks.

37. What is the major difference between posttraumatic stress disorder (PTSD) and acute stress disorder?

a) In acute stress disorder, the client is likely to develop exacerbation of symptoms

b) In PTSD, the symptoms occur 3 months or more after the trauma

c) The severity and duration of the trauma are the most important variables in acute stress disorder

d) In PTSD, the recovery rate is 80% within 3 months

b) In PTSD, the symptoms occur 3 months or more after the trauma

Pg. 528

In acute stress disorder, the symptoms occur 2 days to 4 weeks after a traumatic event and are resolved within 3 months of the event. In PTSD, the symptoms occur 3 months or more after the trauma. In PTSD, the client is likely to develop exacerbation of symptoms. The severity and duration of the trauma and the proximity of the person to the event are the most important factors affecting the likelihood of developing PTSD. In PTSD, complete recovery occurs within 3 months for about 50% of people.

38. The nurse develops a teaching plan for a client who is newly diagnosed with posttraumatic stress disorder (PTSD). Which topic should the nurse include in the client's teaching plan? Select all that apply

a) A safety plan for stressful periods

b) A list of community services, including self-help groups, that are available to the client

c) The importance of a nutritional diet, exercise, and sleep hygiene to optimal functioning

d) Identification of cues that lead to reexperiencing the trauma

e) A list of the client's individual triggers

a) A safety plan for stressful periods

b) A list of community services, including self-help groups, that are available to the client

c) The importance of a nutritional diet, exercise, and sleep hygiene to optimal functioning

d) Identification of cues that lead to reexperiencing the trauma

e) A list of the client's individual triggers

Pg. 525

When caring for a person with a PTSD, the nurse includes the following topic areas in the client's teaching plan: identification of individual triggers and cues that lead to reexperiencing trauma; safety plans for stressful periods; recovery plans that focus on personal strengths; risk factors for reoccurrence of symptoms; various treatment options, such as if one does not help, others exist; avoiding substances such as alcohol and drugs; nutrition; exercise; sleep hygiene; follow-up appointments; and community services.

39. 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?

a) Teaching the client about the factors that cause resilience

b) Modeling interactions that address disruptive behavior disorders

c) Planning activities where the client and the child can bond

d) Teaching the client how to provide culturally safe care for the child

c) Planning activities where the client and the child can bond

Pg. 528

Reactive attachment disorder is characterized by the inability to form positive attachments due to prior neglect. Culturally safe care is always necessary but does not address this child's diagnosis. Teaching about resilience is also relevant but similarly does not address this particular diagnosis that the child already has. Disruptive behavior disorder is not a primary consideration.

40. The medical-surgical nurse has worked with numerous clients who have had difficult and stressful courses of treatment. What client likely faces the greatest risk for developing post-traumatic stress disorder?

a) A client who required a skin graft as a result of an infected surgical incision

b) A client whose chronic kidney disease requires hemodialysis three times per week

c) A child who has endured repeated treatments for cancer over multiple admissions

d) A client with a recent diagnosis of type 1 diabetes who is just learning to use an insulin pump

c) A child who has endured repeated treatments for cancer over multiple admissions

Pg.

Medical problems and hospitalizations are known to be intensely stressful. However, the risk of PTSD is particularly high among cancer survivors, especially those with multiple admissions and prolonged treatment. In a landmark study, childhood cancer survivors have been found to have four times the risk of developing PTSD as their siblings.

41. A client with posttraumatic stress disorder (PTSD) tells the nurse that the client's recent cognitive behavioral therapy has been difficult. The client states that the client's therapist has the client visualize the sights and sounds from the time that the client was assaulted. This client is likely receiving:

a) Cognitive restructuring

b) Cognitive processing therapy

c) Exposure therapy

d) Stress inoculation training

c) Exposure therapy

Pg. 519

Exposure therapy can involve mental imagery of a trauma as well as visits to the actual site. The other listed types of therapy do not normally involve increasing the client's mental or physical engagement with the site of the trauma.

42. 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.

a) Being stranded at the office during a typical winter storm that was anticipated

b) Watching televised segments of the moment when the plane hit the second tower on 9/11

c) Being a marine in a combat situation where the entire platoon was wiped out, except for one person

d) Being hidden in a closet and hearing the entire family murdered by someone who broke into the home

e) Being a survivor of a tsunami that resulted in thousands of deaths

c) Being a marine in a combat situation where the entire platoon was wiped out, except for one person

d) Being hidden in a closet and hearing the entire family murdered by someone who broke into the home

e) Being a survivor of a tsunami that resulted in thousands of deaths

Pg. 515

Examples of events that may cause PTSD include someone experiencing, witnessing (in person), or being confronted by a traumatic event such as a natural disaster, combat, or an assault. 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, and being hidden in a closet and hearing the entire family murdered by an intruder would be situations where the person was exposed to an event that posed actual death or threatened death or serious injury and responded with intense fear, helplessness, or terror. Being stranded at the office is much less likely to be perceived as a risk for death or injury, so is unlikely to result in PTSD. Although witnessing events such as the Twin Towers attack can increase the risk for PTSD, observation typically needs to occur in person; exposure through television or similar media is not included in the diagnositic criteria.

43. A male combat veteran with a diagnosis of post-traumatic stress disorder has been prescribed prazosin. What outcome would most clearly indicate the effectiveness of this treatment?

a) The client states that he is more willing to discuss his trauma

b) The client's family describes him as "more relaxed"

c) The client reports greater energy for accomplishing daily tasks

d) The client reports fewer and less intense nightmares

d) The client reports fewer and less intense nightmares

Pg. 524

Prazosin is used in the treatment of PTSD to improve sleep and relieve nightmares. Outcomes such as increased energy, less hyperarousal and emotional openness would be indirect outcomes of the effects on sleep and nightmares.

44. Which individual is exhibiting signs or symptoms that are characteristic of posttraumatic stress disorder (PTSD)? Select all that apply.

a) A client who is fixated on getting revenge on the business partner whom the client blames for the client's bankruptcy

b) A client who is unable to relax without first barricading the client's home after a violent home invasion and assault

c) A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect

d) A client who has frequent nightmares about the time a fellow soldier died from an improvised explosive device

e) A client who has quit the client's job so that the client no longer has to go to the client's old office where the client was attacked and robbed

b) A client who is unable to relax without first barricading the client's home after a violent home invasion and assault

c) A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect

d) A client who has frequent nightmares about the time a fellow soldier died from an improvised explosive device

e) A client who has quit the client's job so that the client no longer has to go to the client's old office where the client was attacked and robbed

Pg. 515

The diagnostic criteria of PTSD include intrusive symptoms such as nightmares, hyperarousal, hypervigilance, and avoidance of places that remind the person of the traumatic event. A fixation of revenge is not among the diagnostic criteria of PTSD.

45. The advanced practice psychiatric mental health nurse is preparing to begin stress inoculation training with a client who has post-traumatic stress disorder. What should the nurse teach the client about this therapy?

a) "We're going to work to help you develop a new perspective on your traumatic memories"

b) "Together, we'll explore some of the connections between your childhood experiences and your recent trauma"

c) "We're going to work closely with your family to dialogue about the effect that this has had on them"

d) "We're going to work together so that you're eventually able to visit the place where the attack happened"

a) "We're going to work to help you develop a new perspective on your traumatic memories"

Pg. 519

Stress inoculation training is focused on helping clients reframe their memories in a new way. It is not normally used in a family setting and does not consist of exposure. It is not centered on unconscious or childhood memories.

46. The family members of a client with posttraumatic stress disorder (PTSD) state that they are "constantly walking on eggshells" because the client reacts so strongly to stressors that seem inconsequential to them. What is the nurse's best response?

a) Educate the family about the need to set limits assertively but empathically

b) Assess each member of the family for signs and symptoms of PTSD

c) Educate the family about the client's hyperarousal

d) Arrange for respite so that the family can have their emotional needs met

c) Educate the family about the client's hyperarousal

Pg. 516

The client is likely in a state of hyperarousal and educating the family about this phenomenon would be a useful starting point. There is no obvious need for the family to focus on setting limits with the client. Similarly, there is no clear indication of caregiver burnout that would necessitate respite. The family members' sentiment does not indicate a risk of PTSD.

47. A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

a) The adolescent idealizes the relationship that the adolescent had with the sibling

b) The adolescent is fixated on having a fire escape plan in the family's new home

c) The adolescent expresses intense guilt for the inability to save the sibling

d) The adolescent often begins crying when discussing the tragedy

c) The adolescent expresses intense guilt for the inability to save the sibling

Pg. 515

Guilt for not preventing a death is associated with PTSD in adolescents. Crying is an expected response to tragedy, as is focusing on preventing future incidents. Idealizing a relationship after the person's death is not a pathologic behavior.

48. The nurse is working with a client who has been experiencing nightmares, hyperarousal and negative thoughts following a bomb threat at the client's workplace. The nurse's colleague states, "It turned out to be just a threat, not a bombing, so technically she can't have posttraumatic stress disorder (PTSD)." What is the nurse's best response?

a) "PTSD is a real possibility, even though the bombing never actually took place"

b) "Yes, but if the bombing had occurred, I'm sure she'd be diagnosed with PTSD"

c) "If the client responds to prescribed medications, then that will certainly confirm the diagnosis"

d) "Right, but the client's symptoms certainly constitute a diagnosis of adjustment disorder"

a) "PTSD is a real possibility, even though the bombing never actually took place"

Pg. 515

A threatened event is just as "real" as an event that culminates in violence. The client's response to medication has nothing to do with corroborating the diagnosis.

49. What action by a 6-year-old child would most strongly suggest a diagnosis of disinhibited social engagement disorder?

a) The child claims to have dozens of friends but no "best friend"

b) The child has several friends that are much older or much younger than the child

c) The child tells the nurse "secrets" during their initial meetings

d) The child gives adults enthusiastic hugs immediately after meeting them

d) The child gives adults enthusiastic hugs immediately after meeting them

Pg. 528

Disinhibited social engagement disorder is characterized by being overly familiar with strangers. It is not associated with having a large number of diverse friends. The child's willingness to confide in the nurse is not necessarily inappropriate or problematic.

50. The nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) several months ago. During a comprehensive follow-up assessment, what areas should the nurse assess? Select all that apply.

a) Assessment for tardive dyskinesia

b) The effect of the client's PTSD on the family

c) Assessment for extrapyramidal symptoms

d) Characteristics of the client's sleep

e) The client's use of alcohol or other drugs

b) The effect of the client's PTSD on the family

d) Characteristics of the client's sleep

e) The client's use of alcohol or other drugs

Pg. 520

PTSD is strongly associated with substance use and nearly always affects sleep patterns and family life. Extrapyramidal symptoms, such as tardive dyskinesia, are associated with antipsychotics; antipsychotics are not normally used in the treatment of PTSD.