Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders
Halter: Varcarolis’ Foundations of Psychiatric-Mental Health Nursing: A Clinical
Approach, 9th Edition
MULTIPLE CHOICE
1. A nurse works with a client diagnosed with posttraumatic stress disorder (PTSD) who has
frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be
included in the plan of care?
a. Trigger flashbacks intentionally in order to help the client learn to cope with them.
b. Explain that the physical symptoms are related to the psychological state.
c. Encourage repression of memories associated with the traumatic event.
d. Support “numbing” as a temporary way to manage intolerable feelings.
ANS: B
Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal
that can be confusing and distressing. Explaining that these are the body’s responses to
psychological trauma helps the client understand how such symptoms are part of the illness and
something that will respond to treatment. This decreases powerlessness over the symptoms and
helps instill a sense of hope. It also helps the client to understand how relaxation, breathing
exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is
to come to terms with the event so treatment efforts would not include repression of memories or
numbing. Triggering flashbacks would increase client distress.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of
these teenagers most clearly demonstrates resilience?
a. visiting their teenager’s grave daily.
b. returning immediately to employment.
c. discussing the accident within the family only.
d. creating a scholarship fund at their child’s high school.
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 maladaptive grieving. The
parents who create a scholarship fund are openly expressing their feelings and memorializing
their child. The other parents in this question are isolating themselves and/or denying their
feelings. Visiting the grave daily shows active continued mourning but is not as strongly
indicative of resilience as the correct response.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. After the sudden death of his wife, a man says, “I can’t live without her … she was my whole
life.” What is the nurse’s most therapeutic reply?
a. “Each day will get a little better.”
b. “Her death is a terrible loss for you.”
c. “It’s important to recognize that she is no longer suffering.”
d. “Your friends will help you cope with this change in your life.”
ANS: B
Adjustment disorders may be associated with grief. A statement that validates a bereaved
person’s loss is more helpful than false reassurances and clichés. It signifies understanding.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A woman just received notification that her husband died. She approaches the nurse who cared
for him during his last hours and says angrily, “If you had given him your undivided attention, he
would still be alive.” How should the nurse analyze this behavior?
a.
The comment suggests potential allegations of malpractice.
b.
In some cultures, grief is expressed solely through anger.
c.
Anger is an expected emotion in an adjustment disorder.
d.
The client had ambivalent feelings about her husband.
ANS: C
Symptoms of adjustment disorder run the gamut of all forms of distress including guilt,
depression, and anger. Anger may protect the bereaved from facing the devastating reality of
loss.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
5. A wife received news that her husband died of heart failure and called her family to come to the
hospital. She angrily tells the nurse who cared for him, “He would still be alive if you had given
him your undivided attention.” What is the nurse’s best intervention?
a.
Say to the wife, “I understand you are feeling upset. I will stay with you until your
family comes.”
b.
Say to the wife, “Your husband’s heart was so severely damaged that it could no
longer pump.”
c.
Say to the wife, “I will call the health care provider to discuss this matter with
you.”
d.
Hold the wife’s hand in silence until the family arrives.
ANS: A
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)
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?
a. visiting their child’s grave daily.
b. maintaining their child’s room as the child left it 2 years ago.
c. keeping a place set for the dead child at the family dinner table.
d. throwing 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)
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
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. What is the nurse’s
most therapeutic response?
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.”
ANS: D
The client is expressing feelings related to the loss, and this is an expected and healthy behavior.
This client 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 client’s
expression of feelings. Crying at 2 weeks after his death is expected and normal.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
8. Which scenario demonstrates a dissociative fugue?
a.
After being caught in an extramarital affair, a man disappeared but then
b.
c.
d.
reappeared months later with no memory of what occurred while he was missing.
A man is extremely anxious about his problems and sometimes experiences dazed
periods of several minutes passing without conscious awareness of them.
A woman finds unfamiliar clothes in her closet, is recognized when she goes to
new restaurants, and complains of “blackouts” despite not drinking.
A woman reports that when she feels tired or stressed, it seems like her body is not
real and is somehow growing smaller.
ANS: A
The client 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 client (blackouts).
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
9. The nurse who is counseling a client with dissociative identity disorder should understand that
which assessment is of the highest priority?
a. risk for self-harm.
b. cognitive function.
c. memory impairment.
d. condition of self-esteem.
ANS: A
Assessments that relate to client safety take priority. Clients with dissociative disorders may be
at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for selfinjury. 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)
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
10. A client 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?
a. Acute stress disorder
b. Dissociative amnesia
c. Depersonalization disorder
d. Disinhibited social engagement disorder
ANS: C
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 client experiences only one
symptom.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
11. The unlicensed assistive personnel (UAP) says to the nurse, “That client with amnesia looks fine,
but when I talk to her, she seems vague. What should I be doing for her?” What is the nurse’s
best reply?
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.”
ANS: B
Disruptions in ability to perform activities of daily living, confusion, and anxiety are often
apparent in clients 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 client should only gradually be
given information about her past. Asking questions that require recall that the client does not
possess will only add frustration. Quiet, undemanding activities should be provided as the client
tolerates them and should be balanced with rest periods; the client’s time should not be loaded
with demanding or stimulating activities.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
12. A client 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?
a.
Notify the health care provider of this change in the client’s behavior.
b.
Engage the client in a physical activity such as exercise.
c.
Isolate the client until the sensation has diminished.
d.
Administer a prn dose of antianxiety medication.
ANS: B
Helping the client apply a grounding technique, such as exercise, assists the client 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 client. It is not
necessary to notify the health care provider.
PTS: 1
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
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?
a.
Limbic system
b.
Peripheral nervous system
c.
Sympathetic nervous system
d.
Parasympathetic nervous system
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
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?
a. Weight gain
b. Flashbacks
c. Headache
d. Diuresis
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)
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 post-traumatic stress disorder (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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
16. Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The
soldier was diagnosed with post-traumatic stress disorder (PTSD). Which comment by the
soldier requires the nurse’s immediate attention?
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.”
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)
TOP: Nursing Process: Analysis | Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
17. A soldier returned home from active duty in a combat zone and was diagnosed with post-
traumatic stress disorder (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?
a.
Illusion
b.
Flashback
c.
Nightmare
d.
Auditory hallucination
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
18. A soldier returned 3 months ago from a combat zone and was diagnosed with post-traumatic
stress disorder (PTSD). Which social event would be most disturbing for this soldier?
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
ANS: D
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
19. Which comment by the parents of young children best demonstrates support of development of
resilience and effective stress management?
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.”
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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 post-traumatic stress disorder (PTSD) is the soldier
describing?
a.
Re-experiencing
b.
Hyperarousal
c.
Avoidance
d.
Psychosis
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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 posttraumatic stress disorder (PTSD)?
a. Re-experiencing
b. Hyperarousal
c. Avoidance
d. Psychosis
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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.
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.”
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)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
23. Which assessment made by a client best supports dissociative fugue?
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 client 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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
24. After major reconstructive surgery, a client’s wounds dehisced. Extensive wound care was
required for 6 months, causing the client to miss work and social activities. Which physiological
response would be expected for this client?
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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
25. How do relaxation techniques help clients who have experienced major traumas?
a.
By engaging the parasympathetic nervous system.
b.
By increasing sympathetic stimulation.
c.
By increasing their metabolic rate.
d.
By releasing 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)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
26. What is the correct etiology to complete this nursing diagnosis for a client diagnosed with
dissociative identity disorder?
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 clients 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)
TOP: Nursing Process: Analysis | Nursing Process: 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. Post-traumatic stress disorder (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 client’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)
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? (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.
maximizing opportunities for exercise and play.
ANS: A, B, C, E, F
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)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
3. The nurse interviewing a client with suspected post-traumatic stress disorder (PTSD) should be
alert to which client findings? (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.
d.
feels compelled to repeat selected ritualistic behaviors.
e.
demonstrates hypervigilance or distrusts others.
f.
feels detached, estranged, or empty inside.
ANS: A, B, C, E, F
These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors are
expected in obsessive-compulsive disorder.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
4. Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? (Select
all that apply.)
a.
A young adult bungee jumped from a bridge with a best friend.
b.
An 8-year-old child watched an R-rated movie with both parents.
c.
An adolescent was kidnapped and held for 2 years in the home of a sexual
predator.
d.
A passenger was in a bus that overturned on a sharp curve and tumbled down an
embankment.
e.
An adult was trapped for 3 hours at an angle in an elevator after a portion of the
supporting cable breaks.
ANS: C, D, E
PTSD usually occurs after a traumatic event that is outside the range of usual experience.
Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and
natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus
or elevator accident; or crime-related events, such being taken hostage. The common element in
these experiences is the individual’s extraordinary helplessness or powerlessness in the face of
such stressors. Bungee jumps by adolescents are part of the developmental task and might be
frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by
an R-rated movie, but the presence of the parents would modify the experience in a positive way.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity