Which nursing diagnosis should be most useful for clients with anxiety disorders for whom the following defining characteristics have been identified: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, numbing, and flashbacks?

Disturbed Sensory Perception

Anxiety

Post-Trauma Syndrome

Powerlessness

Answer and Explanation

The Correct Answer is C

Choice A reason: Disturbed Sensory Perception involves altered sensory processing, like hallucinations, not specific to anxiety disorders with flashbacks or hypervigilance. These symptoms stem from heightened amygdala activity and dysregulated cortisol in trauma-related disorders, not sensory distortion. This diagnosis is less precise, as it does not capture the trauma-specific psychological and autonomic responses observed.

Choice B reason: Anxiety is a broad diagnosis encompassing excessive worry and autonomic arousal, but it is less specific than Post-Trauma Syndrome for symptoms like flashbacks and numbing. These indicate a trauma-related disorder, likely PTSD, driven by amygdala hyperactivation and HPA axis dysregulation, requiring a diagnosis that addresses the traumatic etiology and specific symptoms.

Choice C reason: Post-Trauma Syndrome, aligned with PTSD, is the most appropriate diagnosis for symptoms like flashbacks, hypervigilance, and numbing, which result from trauma-induced changes in the amygdala, hippocampus, and prefrontal cortex. These cause intrusive memories, heightened arousal, and emotional detachment, accurately reflecting the neurobiological impact of trauma on stress response systems.

Choice D reason: Powerlessness reflects perceived lack of control, not specific to flashbacks or hypervigilance. While trauma can cause feelings of helplessness, the defining symptoms here involve trauma-specific neurological changes, like amygdala hyperactivity, better captured by Post-Trauma Syndrome. Powerlessness is secondary and l

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Correct Answer is D

Explanation

Choice A reason: The belief that clients who talk about suicide are less likely to attempt it is a myth. Verbalizing suicidal ideation often reflects severe distress and heightened risk, as it may indicate prefrontal cortex dysfunction and impaired impulse control. This misconception underestimates the neurobiological basis of suicidal behavior, requiring vigilant assessment.

Choice B reason: Assuming clients who fail a suicide attempt will not try again is incorrect. Previous attempts increase future risk, as suicidal behavior is linked to persistent psychological distress and serotonin dysregulation. This assumption ignores the chronicity of underlying conditions like depression, necessitating ongoing monitoring and intervention to prevent recurrence.

Choice C reason: Claiming failed suicide attempts indicate a lack of intent to die is false. Many attempts fail due to external factors, not lack of intent. Suicidal behavior reflects complex neurobiological factors, including serotonin imbalance and prefrontal cortex deficits, requiring serious intervention regardless of outcome, as intent persists in high-risk individuals.

Choice D reason: A specific suicide plan indicates high risk, as it reflects advanced ideation and intent, often linked to prefrontal cortex dysfunction and reduced impulse control. Detailed planning suggests the client has visualized the act, increasing likelihood of completion. This principle guides nursing care to prioritize safety and immediate psychiatric intervention.

A. If you stop yelling, I will get your dessert B. Don’t you want to finish your meal? C. Let's look at what is on television D. I don't understand what you are saying

Correct Answer is A

Explanation

Choice A reason: Offering dessert to stop yelling uses bargaining, not distraction, and may reinforce agitation in Alzheimer’s, where cortical and amygdala damage impairs emotional regulation. This approach risks escalating distress by focusing on the behavior, which the client cannot control due to neurocognitive deficits, making it ineffective.

Choice B reason: Asking if the client wants to finish the meal focuses on the agitation’s context, potentially worsening distress in Alzheimer’s due to impaired reasoning from cortical degeneration. This confrontational approach does not redirect attention, failing to leverage preserved procedural memory, which distraction techniques use to calm neurobiological agitation.

Choice C reason: Suggesting to watch television is a distraction technique, redirecting attention from agitation triggers in Alzheimer’s. By engaging preserved sensory and procedural memory, it reduces amygdala-driven emotional distress without confronting cognitive deficits, aligning with neurobiological strategies to manage agitation and promote calm in dementia care.

Choice D reason: Stating misunderstanding focuses on the client’s communication deficits, likely increasing frustration in Alzheimer’s due to hippocampal and cortical damage. This does not distract from agitation triggers and may exacerbate distress, as the client cannot process or correct their behavior, making it an ineffective response compared to redirection.

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Which nursing diagnosis should be most useful for clients with anxiety disorders for whom the following defining characteristics have been identified: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, numbing, and flashbacks?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following principles should the nurse apply when planning nursing care for a client who was admitted after a suicide attempt?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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