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24. After major reconstructive surgery, a patient’s wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient?

a. Vital signs return to normal.

b. Release of endogenous opioids would cease.

c. Pulse and blood pressure readings are elevated.

d. Psychomotor abilities of the right brain become limited.

ANS: A

The scenario presents chronic and potentially debilitating stress. The helpless and out of control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses initially result in rapid heart rate and respiration. After many hours, days, or months the body cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous system. This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure. Individuals with dissociative disorders have altered communication between higher and lower brain structures due to the massive release of endogenous opioids at the time of severe threat.

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

REF: Pages 16-15, 16 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

25. Relaxation techniques help patients who have experienced major traumas because they a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

ANS: A

In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

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

REF: Pages 16-30, 31, 36 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

26. Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D

Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

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

REF: Pages 16-50, 68 (Table 16-1) TOP: Nursing Process: Analysis/Diagnosis

MSC: Client Needs: Psychosocial Integrity

Multiple Response

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

ANS: A, B, D

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.

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 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

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