eBay:testbanks_and_xanax

The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-32 (Case Study and Nursing Care Plan), 42, 43, 55

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child’s parents have adapted to their loss? The parents eBay: testbanks_and_xanax a. visit their child’s grave daily. b. maintain their child’s 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.

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-17, 18, 32 (Case Study and Nursing Care Plan) TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity 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. “I’m worried about how much you are crying. Your grief over your husband’s 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.”

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 nurse’s most therapeutic response.

ANS: D

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 nurse’s priority intervention is to form a therapeutic alliance and support the patient’s expression of feelings. Crying at 2 weeks after his death is expected and normal.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 16-55 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity 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.

8. Which scenario demonstrates a dissociative fugue?

ANS: A

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 one’s 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).

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 16-49 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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. b. cognitive function. c. memory impairment. d. condition of self-esteem.

ANS: A

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-53, 54 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

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?

ANS: C eBay: testbanks_and_xanax

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 (Acute Stress Disorder) 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 16-68 (Table 16-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity 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.”

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 nurse’s best reply.

ANS: B

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 patient’s time should not be loaded with demanding or stimulating activities.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-68 (Table 16-2) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. Notify the health care provider of this change in the patient’s 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 antianxiety medication.

12. A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate at this point?

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-8, 10, 48, 69 (Table 16-2)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

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?

ANS: C

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 16-15, 16, 67 (Fig 16-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Weight gain b. Flashbacks c. Headache d. Diuresis

14. The gas pedal on a person’s car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect?

ANS: B

The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or “mind flight” may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 16-45 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

15. A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse’s highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

ANS: C

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-16, 29 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity eBay: testbanks_and_xanax a. “It’s good to be home. I missed my home, family, and friends.” b. “I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.” c. “Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my hometown.” d. “I want to continue my education, but I’m not sure how I will fit in with other college students.”

16. Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse’s immediate attention?

ANS: B

The correct response indicates the soldier is thinking about death and feeling survivor’s guilt. These emotions may accompany suicidal ideation, which warrants the nurse’s follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. 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.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 16-29, 32 (Case Study and Nursing Care Plan)

TOP: Nursing Process: Analysis/Diagnosis

MSC: Client Needs: Psychosocial Integrity a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

17. A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, “If there’s a loud noise at night, I get under my bed because I think we’re getting bombed.” What type of experience has the soldier described?

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 16-6, 43, 44

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment 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

18. A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier?

ANS: D eBay: testbanks_and_xanax

The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 16-6, 43, 44

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment 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.”

19. Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management?

ANS: B

The correct response demonstrates consistent nurturing, which is a vital component of building resilience in children. The incorrect responses are not necessarily unhealthy parenting behaviors, but they do not clearly demonstrate parental nurturing.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 16-14, 18

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

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 PTSD is the soldier describing?

ANS: A

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 16-27 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

21. A soldier who served in a combat zone returned to the United States. The soldier’s spouse complains to the nurse, “We had planned to start a family, but now he won’t talk about it. He won’t even look at children.” The spouse is describing which symptom associated with PTSD?

ANS: C

Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual’s 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 16-29 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. “Posttraumatic stress disorder (PTSD) often changes a person’s 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.”

22. A soldier returned home last year after deployment to a war zone. The soldier’s spouse complains, “We were going to start a family, but now he won’t talk about it. He will not look at children. I wonder if we’re going to make it as a couple.” Select the nurse’s best response.

ANS: D PTSD precipitates changes that can lead to divorce. It is important to provide support to both the veteran and spouse. Confrontation will not be effective. While it is important to provide information, on-going support will be more effective.

PTS: 1

DIF: Cognitive Level: Apply (Application)

REF: Pages 16-24, 31, 51 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

23. Which assessment finding best supports dissociative fugue? The patient states a. “I cannot recall why I’m living in this town.” b. “I feel as if I’m 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.”

ANS: A

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 16-49 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity