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Exhibits

The nurse calms the client and deescalates the situation. The nurse notes that a diagnosis of posttraumatic stress disorder has been added to the care plan.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes that elevated

can cause increased alertness and .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
  • Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.

Rationale for Incorrect Choices:

  • Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
  • Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
  • Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
  • Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Peripheral neuropathy: Although peripheral neuropathy may occur with chronic alcohol use, it is more commonly associated with peripheral nerve damage over time and is not the hallmark of Wernicke's syndrome.

B. Right lower abdominal pain: This is not characteristic of Wernicke's syndrome and is more indicative of appendicitis or gastrointestinal conditions.

C. Confusion: Wernicke’s syndrome (Wernicke’s encephalopathy) is a neurologic disorder caused by thiamine deficiency, often related to chronic alcoholism. Key symptoms include confusion, ataxia, and ophthalmoplegia, making confusion a central assessment to guide care.

D. Depression: While mood disorders can coexist in individuals with alcohol use disorder, depression is not a defining feature of Wernicke’s syndrome and does not guide immediate nursing priorities for this diagnosis.

Correct Answer is B

Explanation

Rationale:

A. Recent change in the ability to read and drive after dark: This may indicate the onset of cataracts or age-related night vision decline, which is common in older adults. While it should be documented and followed up, it is not considered an urgent or emergent finding.

B. Gradual onset of continuous eye pain and blurred vision: This may suggest the development of angle-closure glaucoma or another serious ocular pathology, where increasing intraocular pressure could lead to permanent vision loss if not treated promptly.

C. Cloudy opacity of the crystalline lens: A cloudy lens is characteristic of cataracts, a common, non-urgent age-related change in older adults. Although it affects vision over time, it progresses slowly and can be addressed during routine follow-up care or elective surgery.

D. Gray-white circle around the iris of both eyes: This describes arcus senilis, a benign finding caused by lipid deposits in the corneal margin. It is common with aging and usually has no impact on vision or underlying pathology requiring urgent referral unless seen in younger adults.

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