A patient admitted to the psychiatric hospital and diagnosed with post-traumatic stress disorder (PTSD) asks the nurse what derealization means, as he hears the psychiatrist use that term. The nurse would say which of the following?
“Derealization is an unreality of surroundings.”
“Derealization is the same as hypervigilance.”
“Derealization is a feeling of being detached or as if you are an outside observer.”
“Derealization is a type of therapy used for persons with PTSD.”
The Correct Answer is A
Choice A reason: Derealization refers to the experience of perceiving the external environment as unreal, dreamlike, or distorted. Patients often describe their surroundings as foggy, artificial, or lacking authenticity. This symptom is common in dissociative disorders and can occur in PTSD when the brain attempts to protect itself from overwhelming trauma by altering perception. The unreality of surroundings is the hallmark definition, making this the correct answer.
Choice B reason: Hypervigilance is a heightened state of sensory sensitivity and alertness, often seen in PTSD. It involves scanning the environment for threats and being easily startled. This is not the same as derealization, which is about altered perception of reality rather than increased alertness. Confusing the two would misinform the patient.
Choice C reason: The description in this choice actually refers to depersonalization, not derealization. Depersonalization is the sense of being detached from oneself, as if observing one’s own actions from outside the body. While depersonalization and derealization often co-occur, they are distinct phenomena. This choice is therefore inaccurate for derealization.
Choice D reason: Derealization is not a therapy; it is a symptom. Therapy for PTSD may include cognitive behavioral therapy, EMDR, or exposure therapy, but derealization itself is not a treatment modality. This choice is incorrect because it mislabels a symptom as an intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Sertraline is an SSRI approved for PTSD. It reduces intrusive thoughts, hyperarousal, and avoidance behaviors. Its efficacy is well-documented in clinical trials.
Choice B reason: Lorazepam is a benzodiazepine, not a first-line treatment for PTSD. While it may reduce acute anxiety, it does not address core PTSD symptoms and carries risks of dependence and tolerance.
Choice C reason: Venlafaxine, an SNRI, is effective in treating PTSD. It targets both serotonin and norepinephrine pathways, improving mood regulation and reducing hyperarousal symptoms.
Choice D reason: Paroxetine is an SSRI approved for PTSD. It helps reduce re-experiencing symptoms and improves overall functioning.
Choice E reason: Fluoxetine, another SSRI, is effective in treating PTSD. It improves mood, reduces intrusive memories, and supports long-term symptom management.
Correct Answer is A
Explanation
Choice A reason: Assuming that all individuals within a culture or ethnic group are similar is stereotyping, which disregards individual differences and unique experiences. This approach can lead to biased care, miscommunication, and a lack of respect for the client’s personal identity. Cultural competence requires nurses to assess each client individually rather than generalizing based on group membership. Avoiding assumptions ensures care is patient-centered and respectful.
Choice B reason: Using an interpreter to obtain health information during an assessment is an appropriate and necessary action when language barriers exist. It ensures accurate communication, prevents misunderstandings, and promotes patient safety. Professional interpreters are preferred over family members to maintain confidentiality and accuracy.
Choice C reason: Maintaining eye contact is often considered respectful in many cultures, but nurses must be sensitive to cultural variations. In some cultures, direct eye contact may be perceived as disrespectful or confrontational. However, the nurse’s intent to avoid being rude and uncomfortable is appropriate if tailored to the client’s cultural norms.
Choice D reason: Supporting the client in participating in cultural and spiritual rituals demonstrates respect for cultural values and promotes holistic care. Encouraging such practices can enhance coping, foster trust, and improve patient outcomes. This action aligns with culturally competent nursing practice.
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