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 C

Explanation

Choice A reason: Reminding a dementia patient of forgotten information supports memory function and reduces frustration. Dementia involves progressive neuronal loss, impairing short-term memory due to hippocampal and cortical damage. Gentle reminders align with cognitive support strategies, maintaining patient comfort without overwhelming their limited cognitive capacity, making this approach appropriate.

Choice B reason: Engaging in favorite activities leverages preserved long-term memory in dementia, as the disease primarily affects short-term memory and executive function due to amyloid plaques and tau tangles. Familiar tasks reduce agitation and promote well-being, as they align with the patient’s cognitive abilities, making this a scientifically sound caregiving strategy.

Choice C reason: Introducing new and different activities daily is inappropriate, as dementia patients struggle with learning and adapting due to impaired neuroplasticity and hippocampal dysfunction. Novel tasks can cause confusion and agitation, as they overwhelm cognitive reserves. Familiar routines are more effective, requiring intervention to educate the caregiver on maintaining consistency.

Choice D reason: Encouraging discussion about friends and family taps into preserved long-term memory in early dementia, as the disease initially spares autobiographical memory. Social engagement supports emotional well-being and cognitive stimulation, reducing isolation. This approach is scientifically appropriate, as it aligns with the patient’s cognitive strengths and promotes quality of life.

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?

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Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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