Chapter 12: Dissociative Disorders

Test Bank

Multiple Choice

1. Which question would the nurse performing an admission interview for a patient with suspected dissociative amnesia disorder identify as a priority?

a. What help would you like us to give you?

b. Are you experiencing a high level of anxiety?

c. Do you find rituals make you feel more co mfortable?

d. How would you describe your childhood memories?

ANS: D a. Patient reports a family history of depression b. The onset of symptoms beginning at age 38 c. An abnormality of the patients left heart ventricle d. Complaints of diarrhea and an erratic menstrual cycle

Due to a recent increase in reported cases of dissociative amnesia involving previously forgotten early childhood memories, assessing such memories would have priority with this patient . Obsessive-compulsive disorder is not generally viewed as a co-morbid disorder of dissociative amnesia. The remaining options would not provide much specific information for this patients condition.

2. Which nursing assessment finding would support a diag nosis of somatoform disorder?

ANS: D

The diagnosis of somatization disorder requires that symptoms indicate there is involvement of multiple organ systems (e.g., gastrointestinal, reproductive, neurologic). Structural anomalies would indicate a medical problem exists. An early onset of sympto ms (prior to age 30) is not recognized as a criterion for the diagnosis. A family history of depression is not a criterion for the diagnosis. a. Symptoms are generally associated with pain or sexual function. b. Symptoms are not accounted for by a medical condition. c. Symptoms are precipitated by psychological factors. d. Symptoms are under the patients voluntary control.

3. To differentiate between somatoform and conversion disorders, the nurse will direct the assessment to determine the presence of the critical defining factor associated with conversion disorder. Which is true about a conversion reaction?

ANS: C a. Refers to himself as the patient b. Identifies the onset of increasing anxiety c. Uses manipulative behaviors to meet needs d. Displays ability to suppress feelings of dissatisfaction

Symbolic psychological factors are identified as being related to the onset or exacerbation of a conversion symptom. An absence of a medical cause is present in both the case of conversion and somatization disorders. The conversion symptom is not limited to pain or sexual function nor is not under voluntary control.

4. A diagnosis of dissociative identity disturbance has been identified for a patient who has stated that he is unable to distinguish between himself and his surroundings. What is an appropriate outcome for this patient?

ANS: B

Dissociative identity disturbance is exacerbated when the patients anxiety escalates. Identification of increasing anxiety permits the patient to exercise anxiety- management strategies and prevent dissociation. The patient should be expressing such feelings to others. The patient should refer to himself in the first person. Use of manipulative behavior is not desirable in this or any other patient. a. Inventing the symptom helps in diverting attention from the marital problems. b. Such a traumatic life change is likely to result in some form of mental illness. c. The loss is a protective mechanism to help deal with overwhelming anxiety. d. Men often exhibit this disorder since it is more accepted than showing sadness.

5. A patient comes to the ED stating that he suddenly became deaf. It is determined that his wife has recently asked for a divorce. What is the basis for the possibility that t his patient is experiencing a conversion disorder?

ANS: C a. Evaluating the patients understanding of the emotional effects of the assault b. Asking the patient to keep a journal of her feelings regarding the assault c. Assessing the patient for posttraumatic stress disorder d. Ruling out a physical cause of the pain

The scenario suggests that the patient is experiencing symptoms of conversion disorder, an anxiety disorder in which the symptom affects voluntary sensory or motor function and mimics a neurological disorder as a result of extreme anxiety, such as learning of his wifes desire to divorce him. There is no organic basis for the hearing loss but it is not under the patients voluntary control. Most traumas are not dealt with by developing a mental illness but by rather coping effectively. Males are as likely as females to display conversion disorder symptoms.

6. A patient reports severe pain during intercourse since being sexually assaulted three years ago. What is the first step in confirming the diagnosis of a pain disorder?

ANS: D a. Hearing impairment b. Panic- level anxiety c. Disturbed sensory perception d. Denial due to a medical condition

While psychological factors have an important role in the onset, severity, exacerbation, or maintenance of the pain, initially the presence of a physical cause of the pain must be ruled out. The assessment of the patients understanding of the disorder or recording of feelings regarding the trauma are not priorities until a diagnosis of pain disorder is made. Posttraumatic stress disorder is not generally characterized with reports of sustained pain.

7. A patient has developed an acute loss of hearing and is diagnosed with a co nversion disorder. Which nursing diagnosis would be most appropriate?

ANS: C a. Suggesting to the patient that this is possibly malingering b. Assisting him to make an appointment with an ophthalmologist c. Providing nursing care in a supportive but matter-of- fact manner d. Providing an occupational therapy consult to address the needs of a blind person

The diagnosis of conversion disorder in this case results in a disruption of the patients ability to perceive sensations, not a true loss or impairment of hearing. There is no evidence to support panic- level anxiety or a medical condition causing denial.

8. A patient experiencing the sudden onset of blindness is diagnosed with a conversion disorder. Which nursing intervention would be most therapeutic?

ANS: C

Interacting in a supportive but matter-of- fact way reduces the potential for any secondary reward on the part of the patient. The patient is not feigning illness, so is not a malingerer. An appointment with an eye doctor is not needed since the source of t he blindness is not physical. The person is not permanently blind, so occupational therapy at this point is not a priority. a. Reports, Pain in my back is certainly from a spinal tumor. b. Patient expresses no concern over her sudden loss of hearing. c. Patient shows insight into the role stress plays in the illness. d. Reports, I dont like doctors and so I havent been to one in years.

9. A patient is being evaluated for the diagnosis of hypochondriasis. Which assessment observation of the patient would serve to confirm this diagnosis?

ANS: A a. Continuing to challenge the patient about the rationality of his belief b. Assisting him to reinterpret the meaning of the sensations his body is creating c. Urging him to have a second opinion consult with another medical specialist d. Rewarding him with praise and acceptance when he states, I do not have cancer.

With this disorder, the individual focuses on fears of having or the idea of having a serious medical disorder on the basis of his or her misinterpretation of bodily symptoms such as assuming pain is the result of a tumor. La belle indifference, showing little or no concern, occurs with conversion disorders. Individuals with hypochondriasis make multiple visits to physicians with health concerns. Showing insight into the condition would not be disp layed at the time of diagnosis, since such improvement is a result of appropriate treatment.

10. A patient who inaccurately believes he has stomach cancer is recommended cognitive theory to help address this false believe. Which intervention is most consistent with a cognitive theory approach?

ANS: B

Cognitive theorists believe that patients with somatic symptoms misinterpret the meaning of body functions and sensations and become overly alarmed by them and so help patients to reinterpret the meaning of body sensations. Continuing to challenge the patient regarding the belief is not therapeutic and should be avoided. Reinterpretation of thoughts is an appropriate cognitive approach. Rewarding appropriate behavior is a behavioral technique. Encouraging a second opinion is not helpful at this point since it is not likely to change his belief. a. Reports of pain in both legs and abdomen b. An inability to recall how and when he arrived in this city c. Change in voice and attitude suggesting two distinct personality states d. Inability to see since witnessing an accident that resulted in two deaths

11. The ED nurse is caring for a patient with a dissociative fugue. Which assessment finding would support this diagnosis?

ANS: B

The inability to recall the past is indicative of a fugue disorder. The remaining options are not characteristics of dissociative fugue.

12. A nurse interviews a 17-year-old patient and notes these assessment data: excessive grooming, checking in the mirror, and preoccupation with perceived physical imperfections. The nurse suspects: a. Hypochondriasis b. Factitious disorder c. Somatoform disorder d. Body dysmorphic disorder

ANS: D a. Group therapy is the one therapy of choice for this anxiety disorder. b. Group therapy is therapist driven and managed to eliminate stress on the patients. c. The group will support the patient in all complaints of physical illness as well as emotional distress. d. This therapy allows the patient to learn what has successfully worked for other patients with the disorder.

These symptoms are indicative of a body dysmorphic disorder.

13. The nurse reinforces the recommendation of group therapy for a patient with a somatization disorder. What knowledge is this recommendation based upon?

ANS: D a. Hypnotics, taken appropriately will help with your major complaints. b. Lithium will require regular monitoring to assure therapeutic blood levels. c. Antidepressant therapy may take several weeks to bring about symptom relief. d. Anticonvulsants are often used to treat the side effects of these type of disorders

An advantage of group therapy is that it is an opportunity for the patient to learn from the successes and failures of others with similar symptoms. The group therapist will not allow members to support dysfunctional verbalizations. This disorder is treated with a variety of treatment modalities. This therapy is done with cooperation between therapist and patients.

14. A family member asks the nurse about possible medications to treat somatization disorders. Which statement by the nurse shows an understanding of the recognized medication therapy for this disorder?

ANS: C a. I have learned that my family can be a support system. b. I will let my therapist know if I think suicidal thoughts. c. Drinking strong coffee really helps me combat my fatigue. d. Nicotine makes my heart race, so I need to stop smoking.

Pharmacologic therapy for somatization disorders commonly include antidepressants, which can take weeks of administration before positive effects are noted. The remaining classifications are not generally used to treat somatization disorders.

15. A patient has a somatization disorder. Which statement by the patient would indicate a need for additional patient teaching?

ANS: C a. Do you every have suicidal thoughts? b. Do you worry about being terminally ill? c. Do you see yourself as having problems controlling your anger? d. Do you engage in repetitive, ritualistic behaviors to help control anxiety?

Educating the patient about the importance of limiting caffeine, nicotine, and other central nervous system stimulants is important since these substances can increase physical symptoms of anxiety (e.g., rapid heart rate, jitteriness) that may cue other somatic concerns. Drinking strong coffee each day may cause physical symptoms that could cue other somatic concerns; this statement indicates a need for more teaching. The remaining options are all positive thoughts or actions for a patient.

16. A patient is diagnosed with body dysmorphic disorder. Which question assesses for the presence of a common co -morbid mental disorder?

ANS: A a. An educated African immigrant b. A health care facility employee c. A cognitively challenged female d. A middle-aged American male

Anxiety and depression are common comorbid mental health conditions seen in patients diagnosed with body dysmorphic disorder due to their constant dissatisfaction with their appearance. Obsessive-compulsive disorder, poor impulse control, and somatization disorders are not generally seen in such patients.

17. Which adult patient is most likely a candidate for the diagnosis of factitious disorder?

ANS: B

The adult patients diagnosed with factitious disorder are often knowledgeable regarding medical terminology, and many work in the health care. The other options are not commonly associated with the disorder.

Multiple Response

1. A patient is being treated for somatoform disorder with psychotherapy and medication therapy. Which interventions are appropriate for the patients plan of care? Select all that apply.

a. Instructing the patient in use of imagery to distract themselves when feeling anxious b. Educating the patient on the identification of side effects related to anxiolytic therapy c. Monitoring the patients vital signs to assess for the side effects of benzodiazepine administration d. Discussing the need for long-term cognitive therapy in order to eliminate the symptoms of the disorder e. Asking the patient to explain the role serotonin selective reuptake inhibitors (SSRIs) play in the management of his symptoms.

ANS: A, B, C, E a. Increased willingness to relinquish the sick role b. Decreased anxiety related to possible health issues c. Increased caloric intake and demonstrated weight gain d. Decrease the use of laxatives, sleeping pills, and diuretics e. Experiencing decreased frequency of auditory hallucinations

Pharmacologic interventions are symptom oriented and include anxiolytics for associated anxiety, antidepressants for associated depression, and short-term benzodiazepine therapy. Monitoring for orthostatic hypotension is recommended when benzodiazepines are prescribed. Instructing the patient to perform visual imagery (guided imagery) will reduce anxiety by distracting his or her focus on somatic concerns. When used, cognitive therapy is implemented short term.

2. What discharge criteria would be appropriate for a patient with a somatization disorder? Select all that apply.

ANS: A, B a Ive learned to identify my personal stressors. b. Meditation is a wonderful support in managing my stress. c. Its getting better; Im sleeping about 5 hours most nights. d. I know I have to rely on myself to get this problem under control. e. Ill talk with my doctor before making any changes to my medicines.

Minimization of the use of sickness to gain control and decreased anxiety related to health and wellness are the outcomes that relates specifically to somatization disorder. The remaining options are not typically associated with this disorder.

3. The nurse is evaluating a patient diagnosed with a dissociative disorder for discharge criteria. Which statements made by the patient indicate that discharge criteria have been met? Select all that apply.

ANS: A, B, E

Discharge criteria would include behaviors and attitudes that show insight and some control over the disorder. Compliance with medication therapy, identification of stressors and using learned stress-reducing strategies such as mindfulness meditation are examples of such behaviors. There is a need for more nightly sleep and a willingness to seek help and support are important unmet criteria with this patient.