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 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.
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
Gastrointestinal problems, such as nausea, vomiting, and diarrhea, can be physical signs of acute stress disorder. The stress response can impact the gastrointestinal system due to the activation of the "fight or flight" response.
Choice B rationale:
Cardiovascular problems, such as increased heart rate and blood pressure, are also common physical signs of acute stress disorder. The body's physiological response to stress can lead to cardiovascular changes.
Choice C rationale:
Chronic pain is not typically considered a primary physical sign of acute stress disorder. While stress can exacerbate existing pain conditions, it is not among the hallmark physical symptoms of this disorder.
Choice D rationale:
Substance use disorder might develop as a maladaptive coping mechanism in response to stress, but it is not a direct physical sign that a nurse would observe upon assessment.
Choice E rationale:
Eating disorders are not typically considered a primary physical sign of acute stress disorder. While stress can affect eating habits, it is not one of the characteristic physical symptoms associated with this disorder.
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