A nurse is assessing a client who experienced a traumatic event one week ago. The client is unable to remember important aspects of the event and reports feeling detached from their surroundings. Which symptom is the nurse observing in this client?
Intrusive memories.
Negative mood.
Dissociation.
Avoidance.
Arousal.
The Correct Answer is C
Choice A rationale:
Intrusive memories are characterized by the sudden and distressing re-experiencing of the traumatic event. These memories can be in the form of flashbacks or nightmares and are not directly related to the client's reported inability to remember aspects of the event and feeling detached.
Choice B rationale:
Negative mood, while common in PTSD, pertains to feelings of sadness, anger, or guilt. It is not the primary symptom described in this scenario, where the client is struggling with memory gaps and detachment.
Choice C rationale:
The nurse is observing dissociation in this client. Dissociation involves feeling disconnected from oneself or the environment, often as a defense mechanism in response to trauma. This can manifest as depersonalization (feeling detached from one's own body) or derealization (feeling detached from one's surroundings).
Choice D rationale:
Avoidance refers to the avoidance of reminders or situations associated with the traumatic event. While it can be a symptom of PTSD, it doesn't fully capture the reported memory issues and detachment observed in this client.
Choice E rationale:
Arousal symptoms involve heightened physiological responses such as hypervigilance, irritability, and exaggerated startle responses. These symptoms are not the primary focus of the scenario, which is centered around memory gaps and detachment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Traumatic events can involve serious injuries. This choice accurately reflects that traumatic events can encompass a wide range of situations that result in physical harm, such as accidents, violence, or medical emergencies. These events can lead to significant injuries and medical consequences.
Choice C rationale:
Traumatic events can lead to mental disorders. This choice is correct because traumatic experiences can indeed trigger the development of mental health conditions such as post-traumatic stress disorder (PTSD), depression, anxiety disorders, and more. The emotional impact of trauma can have lasting effects on a person's psychological well-being.
Choice D rationale:
Traumatic events can have long-lasting consequences. This choice is accurate as traumatic events can leave enduring impacts on individuals, affecting their mental, emotional, and physical well-being over an extended period. These consequences can range from chronic psychological distress to changes in behavior and relationships. Now, let's address the incorrect choices:
Choice B rationale:
Traumatic events only include natural disasters. This choice is incorrect because traumatic events are not limited to natural disasters alone. Trauma can result from various experiences, including accidents, violence, abuse, and more. Natural disasters are just one category of traumatic events.
Choice E rationale:
Traumatic events only affect certain age groups. This choice is also incorrect. Traumatic events can affect people of all ages, from children to the elderly. The impact of trauma is not restricted by age; it can influence anyone who experiences or witnesses a distressing event.
Correct Answer is C
Explanation
The answer is choice C
Choice A rationale:
Assisting the client in identifying and challenging negative thoughts might be more appropriate for addressing cognitive distortions in conditions like depression or anxiety disorders, but it might not directly address the alterations in arousal and reactivity characteristic of PTSD.
Choice B rationale:
Encouraging the client to discuss their traumatic experience in detail could potentially trigger retraumatization and exacerbate the symptoms. Exposure therapy, which involves discussing the trauma, is generally done in a controlled and gradual manner under the guidance of a therapist.
Choice C rationale:
Teaching the client grounding techniques to manage anxiety is the most appropriate option. Grounding techniques help individuals stay connected to the present moment, reduce feelings of detachment, and manage anxiety. Techniques might include deep breathing, mindfulness, or using sensory cues to anchor oneself.
Choice D rationale:
Providing the client with a list of community resources for support is important, but it does not directly address the specific symptom cluster of alterations in arousal and reactivity. This intervention might be more relevant for overall support and coping, but not for managing the specific symptoms mentioned.
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