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 C
Explanation
Physical signs.
Choice A rationale:
Psychological signs involve cognitive and mental aspects of PTSD, such as flashbacks and intrusive thoughts.
Choice B rationale:
Emotional signs encompass mood-related manifestations like fear, anger, and guilt.
Choice D rationale:
Social signs refer to difficulties in interpersonal relationships and isolation. In contrast, Choice C, physical signs, include symptoms like headaches and chronic pain which are commonly associated with PTSD due to the physiological stress response triggered by the traumatic event. This response can lead to increased muscle tension and altered pain perception, resulting in these physical symptoms. Such somatic complaints are integral to the diagnosis of PTSD, and they often coexist with other psychological and emotional symptoms.
Correct Answer is B
Explanation
Choice B rationale:
Avoidance symptoms. This choice is accurate because the client's behavior of avoiding the site where the traumatic event occurred is characteristic of avoidance symptoms in PTSD. People with PTSD often go to great lengths to avoid reminders and triggers associated with the trauma. Now, let's address the other choices:
Choice A rationale:
Intrusion symptoms. This choice is incorrect in this context. Intrusion symptoms involve unwanted memories, nightmares, and flashbacks that intrude into a person's consciousness. Avoiding the site of the traumatic event does not align with this symptom cluster.
Choice C rationale:
Negative alterations in cognition and mood. This choice is not applicable to the client's behavior described. Negative alterations in cognition and mood involve feelings of detachment, distorted emotions, and negative beliefs about oneself or the world. Avoiding a specific location does not directly relate to this cluster.
Choice D rationale:
Alterations in arousal and reactivity. This choice is also incorrect for the given behavior. Alterations in arousal and reactivity include symptoms like irritability, hypervigilance, and difficulty concentrating. Avoidance of a particular site is not directly related to this symptom cluster.
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