Trauma, Crisis, Disaster, & Related Disorders

click to highlight the chart entries that require immediate follow up

overheard employee

A nurse is analyzing assessment data for a group of clients. Which of the following clients is at greatest risk of developing PTSD?

A) a 23 year old client who has a tibial fracture following a motor vehicle accident B) a 72 year old client who lost their partner to metastatic breast cancer C) a 29 year old client who has Type I diabetes mellitus & is postoperative following an appendectomy D) a 36 year old client who has a maxillofacial fracture caused by their partner answer: D

A nurse has attended an in service education regarding trauma informed care approach. Which of the following statements by the nurse reflects an accurate description for the goal of a trauma informed approach?

A) a trauma informed approach to care is a process of steps which evaluates injury to determine priority of care B) nurses should focus on immediate client care rather than the trauma that has happened to the client C) trauma informed care is most important in the ED & w/ first responders they see the most trauma D) nurses should understand the effects of trauma & structure client care to promote positive outcomes answer: D

A nurse is providing care for a client who has PTSD. The client states, "I always have to watch my back!" Which of the following manifestations of PTSD is the client experiencing?

A) anosognosia B) hypervigilance C) anhedonia D) dissociative amnesia answer: B

A nurse is caring for a client who was brought to the ER following displacement from their home due to a flood. When assessing the client, which of the following clinical manifestations would the nurse anticipate are related to the experience of trauma?

A) anxiety B) sleep disturbance C) anger D) depression E) hallucinations F) elevated mood answer: A, B, C, D

A nurse is working w/ a local response team to evaluate students following a school shooting. After ensuring the safety of the students, which of the following trauma informed approaches should the team take next?

A) establish a supportive environment that facilitates trust & transparency B) provide resources to students for trauma support & recovery C) explain what trauma is & the symptoms of trauma D) report any students exhibiting inability to cope w/ the traumatic event answer: A

A nurse is caring for a client who was diagnosed w/ adjustment disorder after losing their job 2 months ago. For which of the following manifestations should the nurse monitor the client?

A) persistent avoidance B) psychosis C) dissociative amnesia D) suicidal ideation answer: D

A nurse is developing education for a parenting class about ACEs. Which of the following statements should the nurse include in the education?

A) prior to age 1, children have natural protection from stressors & are unlikely to experience physiological changes from stress B) children who are exposed to repeated ACEs are at an increased risk for developing physical & mental health issues C) experiences of trauma or adverse childhood events result in permanent changes to the brain that cannot be altered D) childrens brains are fully developed by the age 10, & this provides psychological protection from ACEs that occur prior to that age answer: B

A nurse is providing parenting education to a group of new parents at the area community center. Which of the following types of trauma prevention is the nurse providing?

A) secondary prevention B) primary prevention C) primordial prevention D) tertiary prevention answer: B

A nurse at a clinic is screening clients for trauma. The nurse should identify that which of the following factors increases a clients risk for developing a trauma related disorder? (select all that apply)

A) the client has a history of physical abuse B) the client belongs to a marginalized group C) the client was active military during the iraq war D) the client is from a large family E) the client is male F) the client has a stable income answer: A, B, C

A nurse is assigned to triage clients following an explosion at an oil refinery. Which of the following symptoms are consistent w/ a trauma response involving the sympathetic nervous system? (select all that apply)

a) increased HR b) shallow breathing c) muscle tension d) immobility e) anxiety f) fatigue answer: A, B, C, E

Place the following steps of disaster management in the correct order

challenged the community is facing assess resources client has available partner w/ client

which of the following 2 client findings require the nurse to immediately follow up

clients statement regarding harming others clients statement regarding feelings when awakening

A nurse is developing a plan of care for a 14 year old client who has a history of child maltreatment. The staff have reported that any time an alarm occurs, the client is found sitting in a closet. Which of the following most accurately describes the clients response?

A) fear conditioning B) fear extinction C) self regulation D) stress resilience answer: A

A nurse overhears a coworker say, "I get that some people have a hard childhood, but eventually they need to get over it." Which of the following responses should the nurse make?

A) people who have experienced ACEs are only found in vulnerable populations B) it is completely genetics & biology; some people are just unable to get over their past & move on C) people who experience ACEs are changed biologically & genetically D) it is only people who experience trauma later in life who will really struggle answer: C

A nurse is providing care to a 4 year old child who has recently been diagnosed w/ reactive attachment disorder. Which of the following statements by the nurse accurately describes this disorder?

A) the child developed reactive attachment disorder because they were bitten by a dog 2 weeks ago B) this child displays inappropriate attachment & is overly familiar w/ a stranger C) reactive attachment disorder can occur when there is an absence of adequate caregiving, including the child going many hours without being held or touched as an infant D) the child has recurring nightmares & often displays outbursts of anger even when they are not provoked by others answer: C

A nurse is caring for a client following a suicide attempt. Which of the following statements by the nurse reflects a trauma informed approach?

A) this must be difficult. can you tell me about what happened to you B) you are new to the unit. why are you here C) you sit alone. Do you really want to be here D) you seem in pain. why did you try to harm yourself answer: A

For each potential nursing intervention, click to specify if the potential intervention is expected, nonessential, or contraindicated for the client

Expected Contraindicated Contraindicated Contraindicated expected nonessential

A nurse is caring for a client who was recently diagnosed w/ PTSD. The client asks, "What is the difference between acute stress disorder & PTSD?" Which of the following responses should the nurse make?

A) with acute stress disorder, the traumatic experience & response to it is less severe B) PTSD is diagnosed if the symptoms persist for longer than 1 month C) PTSD can only be diagnosed if the trauma is experienced firsthand D) acute stress disorder does not involve arousal symptoms or negative alterations in mood answer: B

A nurse is preparing educational material for guardians on trauma prevention, & developing childhood resilience. Which of the following techniques should the nurse include? (select all that apply)

A) foster a hopeful perspective of the future B) encourage development of thinking & learning C) provide secure & supportive relationships & places D) ignore tantrums E) discourage expression of anger F) insist the child verbalizes emotional needs answer: A, B, C

A nurse is providing care for an adolescent who sustained injuries in assault. Which of the following actions should the nurse take first?

A) identify the adolescents coping strategies & skills B) explore the adolescents feelings about the assault C) provide a safe, secure environment for the adolescent D) provide the adolescent w/ information on support groups answer: C

A nurse is preparing a teaching for high school students regarding trauma & interpersonal violence. Which of the following statements should the nurse plan to include in the teaching?

A) interpersonal violence includes physical, sexual, & emotional maltreatment, which are types of trauma B) interpersonal violence are acts of aggression occurs between two adults & is a form of sexual maltreatment C) interpersonal violence occurs most frequently between people who do not know each other D) interpersonal violence is the result of unintentional force & maltreatment against another person answer: A

A community health nurse observes an 8 month child being reunited w/ their parent after being found alone in an automobile. Which of the following responses should the nurse identify as an indication that the child might be experiencing poor attachment? (select all that apply)

A) the child continues to play w/ a toy when their parent steps into the room B) the child does not respond when held & embraced by the parent C) the child reaches out to the parent when they enter the room D) the child selects a toy offered them & begins to play while sitting on their parents lap E) the child cries when the nurse tries to give the child to the parent answer: A, B, E

A nurse has attended an in service regarding nursing care for clients who have experienced trauma. Which of the following statements by the nurse represents an understanding of trauma?

A) trauma is usually a series of events rather than a one time occurrence B) trauma is a specific term used to describe visible wounds that a client has experienced C) trauma is a broad term that refers to a persons physical, psychological, or emotional response to an adverse event D) trauma is predominately experienced in adulthood as children cannot recognize trauma answer: C

A nurse is caring for a client who has depression, diabetic polyneuropathy, & significant neuropathic pain. The nurse hears an assistive personal say, "They are admitted frequently & always report being in pain. I think they are just a drug seeker." Which of the following responses should the nurse make?

A) you certainly call things like you see them. I am going to ignore that you said that B) yes, this client is always in pain. you should remember that it is our job to take care of people like them C) what is bothering you? just keep your comments & opinions to yourself D) it is not appropriate to stereotype clients. it seems like you may have bias which could affect client care answer: D