Question

Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake during a recent tourist trip to Syria. After his return to USA, he began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. On an interview with the nurse the client stated the following: "I saw my best friend get killed by a falling building. It should have been me instead." Identify the distinctive symptoms of PTSD in previous scenario

Answer 1

Correct Answers:

Guilt
Nightmares
Avoidance
Flashback

Rationale :

💎 Guilt: Survivor’s guilt (“It should have been me”) is a core emotional feature of PTSD, reflecting self-blame after trauma.

💎 Nightmares: Re-experiencing the trauma through distressing dreams is a hallmark PTSD symptom.

💎 Avoidance: The client avoids reminders (thoughts, feelings, situations) related to the trauma by staying busy.

💎 Flashbacks: Intrusive images or memories replaying the traumatic event are typical PTSD re-experiencing symptoms.

💎 Cluster link: PTSD symptoms fall into four clusters: intrusion (flashbacks, nightmares), avoidance, negative mood (guilt), and hyperarousal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

"I check where my car keys are eight times."

Rationale :

🔷 OCD indicator: Repetitive checking behaviors stem from compulsions meant to reduce anxiety from intrusive thoughts.

🔷 Intrusive obsession: The person fears losing or misplacing something critical, triggering repetitive rituals.

🔷 Behavioral reinforcement: The ritual temporarily relieves anxiety, reinforcing the cycle of obsessions and compulsions.

🔷 Differentiation: PTSD involves re-experiencing trauma; OCD involves irrational repetitive behaviors.

🔷 Nursing implication: Help the client identify triggers and introduce gradual exposure and response prevention strategies.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

"Is it difficult to keep certain thoughts out of awareness?"
"Do you do certain things over and over again?"
"Do you have to do things in a certain way to feel comfortable?"

Rationale :

💠 Intrusive thoughts: Persistent, unwanted thoughts that are hard to ignore are obsessions.

💠 Repetitive actions: Performing tasks repeatedly (e.g., washing, checking) represents compulsions.

💠 Rigid routines: Needing actions “done a certain way” reflects ritualistic behavior linked to anxiety reduction.

💠 Social discomfort: Refers to social anxiety, not OCD.

💠 Trauma exposure: Relates to PTSD, not OCD.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"I saw my best friend get killed by a falling building. It should have been me instead."

Rationale :

🟢 Immediate concern: Expression of survivor’s guilt indicates potential suicidal ideation and self-blame.

🟢 PTSD risk: Guilt and self-directed anger can lead to hopelessness or suicidal behavior if unaddressed.

🟢 Priority: Assess for suicidal thoughts, plan, and intent — this is a safety emergency.

🟢 Other statements: Reflect distress and adjustment, but not imminent danger.

🟢 Intervention: Use therapeutic communication and ensure immediate safety precautions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Social Isolation related to avoidance of public situations perceived as unsafe

Rationale :

🔶 Condition: The client exhibits agoraphobia, characterized by fear of leaving home or being in open/public spaces.

🔶 Behavior: Avoids outside activities, depends on others, and fears being unable to escape or get help.

🔶 Functional impact: Social withdrawal leads to isolation and decreased quality of life.

🔶 Nursing focus: Gradual exposure to feared situations, anxiety management, and building self-efficacy.

🔶 Priority: Address avoidance behaviors to rebuild independence and social connection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Flashback

Rationale :

💎 Definition: A flashback is a dissociative reaction in which the person re-experiences the traumatic event as if it were happening again in the present moment.

💎 Example fit: Mike dives under his bed when hearing a loud noise, believing he’s “getting bombed”—a classic PTSD flashback response.

💎 Key distinction: Flashbacks differ from nightmares (which occur during sleep) and from illusions/hallucinations (which are sensory misperceptions without external triggers).

💎 Physiologic response: The autonomic nervous system activates (fight-flight-freeze), mimicking the original trauma.

💎 Clinical focus: Nurses ensure safety, help with grounding techniques, and avoid sudden touch or loud noises during an episode.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Panic

Rationale :

🔷 Behavioral signs: Running, crying, and not responding to verbal directions reflect loss of control and disorganization—hallmarks of panic-level anxiety.

🔷 Cognitive state: At panic level, perception is severely narrowed; the client cannot focus, think clearly, or follow commands.

🔷 Physical symptoms: Trembling, hyperactivity, and distorted reality perception are common.

🔷 Intervention: The nurse should ensure safety, use calm voice, reduce stimuli, and stay physically present until the client stabilizes.

🔷 Mild/Moderate: Still responsive, able to learn.

🔷Severe: Distorted perception but may still hear the nurse.

🔷Panic: Total loss of control, possible hallucination-like reactions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

I saw my friend get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind.

Rationale :

💠 Defining feature: Recurrent intrusive flashbacks or visual images of the traumatic event are core PTSD re-experiencing symptoms.

💠 Temporal link: Occurring long after the trauma (“over a year ago”) shows the persistent nature of PTSD.

💠 Trigger cue: Visual reminders (“something red”) cause automatic trauma recall, consistent with sensory triggers.

💠 Distinction: Other statements reflect adjustment issues or anxiety but lack intrusive trauma re-experiencing.

💠 Clinical implication: These clients often need trauma-focused therapy and grounding interventions to reconnect with present reality.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Chronic distress can take a toll on the individual.

Rationale :

🟢 Definition: Chronic stress leads to sustained sympathetic activation, damaging body systems (cardiovascular, immune, endocrine).

🟢 Effects: Includes hypertension, weakened immunity, sleep disorders, and mental health decline.

🟢 Eustress vs. Distress: Eustress is short-term and motivating; distress is prolonged and health-damaging.

🟢 Nursing relevance: Encourage stress management techniques (exercise, mindfulness, relaxation) to prevent burnout.

🟢 Pathophysiology: Prolonged cortisol elevation disrupts homeostasis and increases risk for chronic illness.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Having persistent thoughts about bacteria, germs, and dirt

Rationale :

🔶 OCD trigger: Obsessive thoughts about contamination trigger compulsive cleaning behaviors to reduce anxiety.

🔶 Etiologic link: “Inability to control compulsive cleaning” arises from recurrent intrusive obsessions about germs, not social or relational needs.

🔶 Compulsion purpose: Cleaning is a ritual that temporarily relieves anxiety from the obsessive thoughts.

🔶 Differentiation: Other options describe secondary motives (approval, avoidance), not the primary OCD driver.

🔶 Nursing care: Focus on anxiety reduction, gradual exposure, and response prevention therapy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

2 :
Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?

3 :
Which assessment questions are most relevant to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

9 :
Although stress may result from either a positive or a negative event, the physical effects are similar. Which statement best describes the long-term effects of stress?

10 :
A client has the following nursing diagnosis: Emotional discomfort as evidenced by an inability to control compulsive cleaning. Which phrase referring to the likely trigger correctly completes the etiological portion of the diagnosis?

QLexNursing

2 : Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?

3 : Which assessment questions are most relevant to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

9 : Although stress may result from either a positive or a negative event, the physical effects are similar. Which statement best describes the long-term effects of stress?

10 : A client has the following nursing diagnosis: Emotional discomfort as evidenced by an inability to control compulsive cleaning. Which phrase referring to the likely trigger correctly completes the etiological portion of the diagnosis?

2 :
Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?

3 :
Which assessment questions are most relevant to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

9 :
Although stress may result from either a positive or a negative event, the physical effects are similar. Which statement best describes the long-term effects of stress?

10 :
A client has the following nursing diagnosis: Emotional discomfort as evidenced by an inability to control compulsive cleaning. Which phrase referring to the likely trigger correctly completes the etiological portion of the diagnosis?