1. A young adult says, “I was sexually abused by my older brother. During those assaults, I went
somewhere else in my mind. I don’t 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. PTSD e. Reactive attachment disorder f. Disinhibited social engagement disorder
an ax
ANS: A, B, D
_x
Acute stress disorder, depersonalization disorder, and PTSD 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 patient’s 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.
_a
nd
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 16-3, 5 (DSM-5 Box), 29, 37 (DSM-5 Box), 48, 49 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. A 10-year-old child was placed in a foster home after being removed from parental contact
es
tb
an
ks
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 child’s 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. ANS: A, B, C, E
eB
ay
:t
The child’s symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child’s 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 16-24 to 26, 71 (Box 16-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
3. The nurse interviewing a patient with suspected PTSD 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 re-experiences the trauma. c. experiences symptoms suggestive of a heart attack.
eBay: testbanks_and_xanax
