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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Phenytoin, an anticonvulsant, is not routinely given before ECT, as the procedure induces controlled seizures to stimulate brain activity, treating depression via neurochemical changes. Administering phenytoin would inhibit seizure activity, reducing ECT efficacy by blocking neuronal excitability, making this an inappropriate action for the procedure.
Choice B reason: Instructing about post-ECT headaches is valid, as they result from cerebral vasoconstriction or muscle tension during seizures. However, this is a post-procedure expectation, not a priority action during planning. Monitoring cardiac rhythm takes precedence, as ECT’s autonomic stimulation poses immediate cardiovascular risks requiring real-time management.
Choice C reason: Monitoring cardiac rhythm during ECT is critical, as the procedure induces seizures that stimulate the autonomic nervous system, causing transient tachycardia or arrhythmias due to catecholamine surges. These can exacerbate underlying cardiac conditions, risking instability. Continuous monitoring ensures early detection and management of cardiovascular complications, prioritizing patient safety.
Choice D reason: Four-point restraints are not used in ECT, as patients are under general anesthesia, preventing movement. Restraints risk injury and are unnecessary, as muscle relaxants like succinylcholine minimize convulsive movements. This approach contradicts ECT’s controlled, anesthetized protocol, making it inappropriate for ensuring safety during the procedure.
Correct Answer is C
Explanation
Choice A reason: Responding positively to flattery risks reinforcing manipulative behavior and does not address potential underlying distress. The client’s statement may reflect emotional dysregulation or suicidal ideation, common in psychiatric conditions with serotonin imbalances. This response fails to probe for serious neurobiological risks, missing a critical assessment opportunity.
Choice B reason: Assuming the client wants something is confrontational and dismissive, ignoring potential suicidal ideation or emotional distress. The statement may reflect serotonin-driven mood instability or a cry for help, requiring sensitive exploration. This response risks alienating the client, missing neurobiological cues for underlying psychiatric concerns.
Choice C reason: Asking about suicidal thoughts is appropriate, as the client’s statement may signal ideation, linked to serotonin dysregulation and prefrontal cortex deficits. Such expressions can indicate despair or intent in psychiatric conditions, necessitating direct assessment to ensure safety and address potential neurobiological imbalances driving suicidal behavior.
Choice D reason: Dismissing the statement as insincere ignores potential distress signals, such as suicidal ideation or emotional dysregulation from serotonin imbalances. This response fails to engage the client’s underlying neurobiological state, risking missed opportunities to assess serious psychiatric concerns and provide appropriate intervention or support.
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