Abuse, Violence, Trauma, and Stressor Related Disorders Chapters

Abuse, Violence, Trauma, and Stressor Related Disorders

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Study Questions

Clinical Picture of Abuse and Violence

Question 1 :A nurse is educating a group of nursing students about the different types of abuse. Which statement accurately describes elder abuse?

A. Elder abuse involves harm or distress caused by an older person to a younger family member. B. Elder abuse is limited to physical harm caused by a caregiver to an older adult. C. Elder abuse includes emotional harm caused by intimate partners to older adults. D. Elder abuse encompasses financial exploitation of older individuals by trusted persons.

Explanation

Choice A rationale:

Elder abuse is not primarily about harm caused by an older person to a younger family member. Instead, it revolves around mistreatment of older individuals.

Choice B rationale:

While physical harm can be a form of elder abuse, it is not the only type. Elder abuse encompasses various forms, including emotional, financial, and neglectful mistreatment.

Choice C rationale:

Elder abuse isn't limited to harm caused by intimate partners. It can involve various relationships, including family members, caregivers, and other individuals.

Choice D rationale:

This is the correct choice. Elder abuse often involves financial exploitation, where individuals in positions of trust take advantage of older persons' assets or funds. This can include improper use of funds, fraud, and manipulation of finances.

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Question 2 :(Select all that apply): A nurse is discussing the factors contributing to abuse and violence. Which factors are considered individual factors contributing to abuse and violence? Select all that apply.

A. Low socioeconomic status. B. History of trauma or abuse. C. Poor communication skills. D. Unemployment. E. Lack of access to education.

Explanation

Choice A rationale:

Low socioeconomic status can contribute to stress and frustration, increasing the likelihood of abusive behavior. Financial struggles may exacerbate tensions in relationships.

Choice B rationale:

A history of trauma or abuse can perpetuate a cycle of violence. Individuals who have experienced trauma may struggle with coping mechanisms and interpersonal relationships, potentially leading to abusive behavior.

Choice C rationale:

Poor communication skills can lead to misunderstandings, frustration, and escalation of conflicts, which can contribute to abusive interactions.

Choice D rationale:

Unemployment, while a societal factor, is not typically classified as an individual factor contributing to abuse and violence. It's more related to economic stress.

Choice E rationale:

Lack of access to education can limit individuals' ability to understand healthy relationship dynamics and conflict resolution, potentially contributing to abusive behavior.

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Question 3 :A client who has experienced abuse states, "I feel so isolated and worthless." What appropriate response by the nurse can help address the emotional effects of abuse?

A. "You shouldn't feel that way. You're not alone.” B. "Many people go through tough times, but you'll get over it.” C. "It's understandable that you're feeling this way. We're here to support you.” D. "I think you're exaggerating your feelings. Try to focus on the positive aspects.”

Explanation

Choice A rationale:

Dismissing the client's feelings by saying "you shouldn't feel that way" invalidates their emotions and does not provide the needed support.

Choice B rationale:

Minimizing the client's feelings by suggesting that they will "get over it" can further isolate them and hinder their ability to express their emotions.

Choice C rationale:

This is the correct choice. Validating the client's feelings and offering support is crucial. Acknowledging their emotions and assuring them of available support promotes a therapeutic relationship.

Choice D rationale:

Invalidating the client's feelings and implying they are exaggerating can worsen their emotional state and discourage them from seeking help.

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Question 4 :A nurse caring for a victim of sexual assault hears the client say, "I can't believe this happened to me. I must have done something to deserve it." What therapeutic response should the nurse provide?

A. "You're right, you should have been more cautious.” B. "It's important to focus on moving forward rather than dwelling on the past.” C. "No one deserves to be assaulted. It's not your fault.” D. "Let's try not to think about it too much, okay?”

Explanation

Choice A rationale:

Choice A suggests blaming the victim by implying that they should have been more cautious, which is not a therapeutic response. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.

Choice B rationale:

Choice B advises the victim to move forward and not dwell on the past, which might minimize the emotional impact of the assault. While moving forward is important, it is equally important to acknowledge the victim's feelings and provide support.

Choice C rationale:

Choice C is the correct therapeutic response. It reassures the victim that the assault was not their fault and emphasizes that nobody deserves to be assaulted. This response promotes healing, self-worth, and reduces feelings of self-blame.

Choice D rationale:

Choice D dismisses the victim's feelings by suggesting not to think about the assault. Avoiding discussing the issue can hinder the victim's recovery process and prevent them from addressing their emotions.

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Question 5 :A nurse is conducting a community workshop on abuse prevention. Which type of violence involves interpersonal acts that occur between unrelated individuals in public or private spaces?

A. Child abuse. B. Intimate partner violence. C. Elder abuse. D. Community violence. Now, I'll provide three additional questions from online sources related to the same topic:

Explanation

Choice A rationale:

Child abuse involves violence directed at minors within families or guardianships. It doesn't necessarily involve unrelated individuals in public or private spaces.

Choice B rationale:

Intimate partner violence refers to abuse within romantic relationships, which may occur in private spaces but isn't limited to unrelated individuals.

Choice C rationale:

Elder abuse pertains to violence against the elderly, typically within caregiving relationships, and doesn't focus on unrelated individuals in public spaces.

Choice D rationale:

Choice D is the correct answer. Community violence encompasses interpersonal acts occurring between unrelated individuals in public or private settings. This includes incidents like street violence, muggings, and other forms of random violence.

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Question 6 :Which psychological disorder is commonly associated with the aftermath of abuse and violence?

A. Bipolar disorder. B. Obsessive-compulsive disorder. C. Schizophrenia. D. Post-traumatic stress disorder.

Explanation

Choice A rationale:

Bipolar disorder involves mood swings between manic and depressive states, but it's not directly associated with the aftermath of abuse and violence.

Choice B rationale:

Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts and compulsive behaviors, but it's not a primary psychological disorder associated with abuse and violence aftermath.

Choice C rationale:

Schizophrenia involves disorganized thinking, hallucinations, and delusions, but it's not typically linked to the aftermath of abuse or violence.

Choice D rationale:

Choice D is the correct answer. PTSD commonly arises after exposure to traumatic events, such as abuse and violence. It leads to symptoms like flashbacks, nightmares, hypervigilance, and emotional numbing, often impacting the victim's mental and emotional well-being.

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Question 7 :A nurse is caring for a child who exhibits unexplained injuries and has a history of being absent from school frequently. What should be the nurse's initial action?

A. Confront the parents about potential abuse. B. Document the findings and inform the school counselor. C. Wait for the parents to mention the injuries. D. Notify Child Protective Services immediately.

Explanation

Choice A rationale:

Confronting the parents about potential abuse might escalate the situation and put the child at further risk. The nurse's priority is ensuring the child's safety, and confronting the parents directly without proper evidence or professional intervention could lead to unintended consequences.

Choice B rationale:

While documenting the findings and informing the school counselor is an important step, it should not be the initial action. The nurse's primary responsibility is to protect the child's welfare, and informing the school counselor alone might not ensure immediate intervention.

Choice C rationale:

Waiting for the parents to mention the injuries is not appropriate because it delays necessary intervention. If the child is indeed being abused, waiting for the parents to mention the injuries could prolong the child's suffering and jeopardize their safety.

Choice D rationale:

Notifying Child Protective Services (CPS) immediately is the correct initial action. When a child exhibits unexplained injuries along with a history of frequent absences from school, it raises concerns for potential abuse or neglect. CPS has the authority and expertise to conduct thorough investigations and take appropriate actions to ensure the child's safety.

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Question 8 :(Select all that apply): A nurse is educating a group of caregivers about elder abuse prevention. Which strategies can help prevent elder abuse? Select all that apply.

A. Encouraging social isolation to avoid potential harm. B. Providing caregivers with stress management techniques. C. Educating caregivers about financial exploitation risks. D. Establishing regular communication between caregivers and older adults. E. Promoting awareness about community resources for elder support.

Explanation

Choice A rationale:

Encouraging social isolation is not a strategy for elder abuse prevention. Isolating older adults can actually increase their vulnerability to abuse, as they may lose contact with people who could offer help and support.

Choice B rationale:

Providing caregivers with stress management techniques is an effective strategy. Caregivers often experience high levels of stress, which can sometimes contribute to abusive behavior. Teaching them healthy ways to cope with stress can reduce the likelihood of abuse.

Choice C rationale:

Educating caregivers about financial exploitation risks is crucial. Elder financial abuse is a common form of mistreatment. By educating caregivers about the signs of financial exploitation and how to prevent it, older adults are less likely to be taken advantage of.

Choice D rationale:

Establishing regular communication between caregivers and older adults is important. Open communication channels allow caregivers to identify and address potential issues early on, reducing the risk of abuse or neglect.

Choice E rationale:

Promoting awareness about community resources for elder support is essential. Providing caregivers with information about available resources, such as support groups, helplines, and services, empowers them to seek help when needed and decreases the likelihood of abusive situations.

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Child Abuse

Question 9 :A nurse is assessing a child who presents with bruises in various stages of healing on the back, buttocks, and arms. The nurse should suspect which type of abuse based on these findings?

A. Emotional abuse. B. Neglect. C. Sexual abuse. D. Physical abuse.

Explanation

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Question 10 :Select all that apply: A nurse is educating a group of parents about child abuse prevention. What primary prevention strategies should the nurse include in the teaching? (Select all that apply).

A. Stress management techniques. B. Conflict resolution skills. C. Substance use prevention strategies. D. Providing home visits to at-risk families. E. Teaching appropriate use of weapons.

Explanation

Choice A rationale:

Stress management techniques are not directly related to child abuse prevention. While teaching parents and children how to manage stress can be beneficial for overall well-being, it is not a primary prevention strategy specifically focused on preventing child abuse.

Choice B rationale:

Conflict resolution skills are an important aspect of preventing child abuse. Teaching parents and children effective ways to resolve conflicts can reduce the likelihood of situations escalating to the point of abuse. This choice is relevant because it empowers individuals to handle disagreements and stressors without resorting to harmful behaviors.

Choice C rationale:

Substance use prevention strategies are crucial in preventing child abuse. Substance abuse can impair judgment and increase the risk of abusive behaviors. By educating parents about the risks of substance abuse and providing strategies to avoid it, the nurse contributes to a safer environment for children.

Choice D rationale:

Providing home visits to at-risk families is a secondary prevention strategy. While it allows professionals to assess the family's situation and offer support, it doesn't directly address the broader community education and awareness that primary prevention entails.

Choice E rationale:

Teaching appropriate use of weapons is not a primary prevention strategy for child abuse. In fact, discussing weapons in the context of child abuse prevention could be counterproductive and potentially dangerous.

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Question 11 :A nurse is conducting a nursing assessment on a child suspected of being a victim of abuse. Which statement by the nurse would facilitate effective communication?

A. "Why did this happen to you?" B. "Did your parents hurt you?" C. "Can you tell me what happened?" D. "You must be feeling scared, right?”

Explanation

Choice A rationale:

Asking "Why did this happen to you?" could come across as accusatory and judgmental, potentially shutting down effective communication. It might make the child defensive or reluctant to share their experience.

Choice B rationale:

While "Did your parents hurt you?" is a direct question, it might be too blunt and may not encourage the child to open up. The child might feel pressured or fearful to respond truthfully.

Choice C rationale:

"Can you tell me what happened?" is an open-ended question that encourages the child to share their experience in their own words. It allows the child to feel more in control of the conversation and to disclose information at their own pace.

Choice D rationale:

"You must be feeling scared, right?" assumes the child's emotions and can be leading. It's better to let the child express their feelings without suggesting specific emotions.

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Question 12 :During a nursing assessment, a child shows signs of fear, withdrawal, and difficulty expressing emotions. Which statement by the child supports the suspicion of emotional abuse?

A. "My parents hit me sometimes." B. "I don't feel safe at home." C. "I can't make any friends." D. "Nobody cares about me.”

Explanation

Choice A rationale:

While "My parents hit me sometimes" is concerning and indicative of potential physical abuse, it does not specifically support the suspicion of emotional abuse.

Choice B rationale:

"I don't feel safe at home" is a statement that directly implies emotional distress and raises suspicion of emotional abuse. Feeling unsafe at home can suggest a hostile or threatening environment that goes beyond physical harm.

Choice C rationale:

"I can't make any friends" hints at potential social difficulties but does not necessarily indicate emotional abuse. It could have various causes, such as shyness or social skills challenges.

Choice D rationale:

"Nobody cares about me" suggests feelings of neglect and isolation, which could be associated with emotional abuse. However, it's not as directly indicative of emotional abuse as the statement in choice B.

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Question 13 :A nurse is evaluating the outcomes of care for a child who has experienced abuse. Which outcome indicates a positive response to intervention?

A. The child avoids expressing emotions. B. The child's injuries remain unchanged. C. The child demonstrates improved social skills. D. The child reports occasional suicidal thoughts.

Explanation

Choice A rationale:

Avoiding expressing emotions is not a positive outcome in the context of a child who has experienced abuse. This could indicate emotional suppression or difficulty in coping with emotions, which are not healthy responses to intervention.

Choice B rationale:

If the child's injuries remain unchanged, it suggests that the intervention has not effectively addressed the safety and well-being of the child. The lack of improvement in physical condition is not a positive outcome.

Choice C rationale:

The correct answer. Improved social skills indicate positive progress in the child's overall well-being. Enhancing social skills suggests that the child is developing healthier interpersonal relationships, which is a positive response to intervention.

Choice D rationale:

Reporting occasional suicidal thoughts is not a positive outcome. It indicates that the child is still experiencing significant emotional distress and may require further intervention to address their mental health and emotional well-being.

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Question 14 : What is the main objective of nursing interventions for child abuse?

A. Isolating the child from the family. B. Punishing the abusers severely. C. Reporting every suspected case to the authorities. D. Protecting the child, promoting safety, and supporting healing.

Explanation

Choice A rationale:

Isolating the child from the family can lead to further emotional trauma and disruption of healthy relationships. The main objective of nursing interventions is to ensure the child's well-being while maintaining their support systems whenever possible.

Choice B rationale:

While consequences for abusers are important, the main objective of nursing interventions is to prioritize the safety, healing, and well-being of the child. Punishment alone does not address the holistic needs of the child.

Choice C rationale:

Reporting every suspected case to the authorities might be legally required, but it is not the main objective of nursing interventions for child abuse. Nursing interventions focus on directly assisting the child and their healing process.

Choice D rationale:

The correct answer. The main objective of nursing interventions for child abuse is to ensure the child's safety, protect them from harm, and support their physical and emotional healing. This holistic approach addresses the immediate crisis and promotes long-term well-being.

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Question 15 : A nurse is assessing a child with suspected abuse. Which factor is essential during the nursing assessment of child abuse?

A. Using leading and suggestive questions. B. Conducting the assessment in a public place. C. Involving the child's peers in the assessment process. D. Performing the assessment in a safe and private environment.

Explanation

Choice A rationale:

Using leading and suggestive questions can influence the child's responses and potentially compromise the accuracy of the assessment. Open-ended, non-leading questions are essential to gather unbiased information.

Choice B rationale:

Conducting the assessment in a public place may expose the child to embarrassment or discomfort, inhibiting them from openly discussing their experiences. A safe and private environment encourages the child to share sensitive information.

Choice C rationale:

Involving the child's peers in the assessment process can lead to breaches of confidentiality and might not create a conducive environment for the child to disclose their experiences honestly.

Choice D rationale:

The correct answer. Performing the assessment in a safe and private environment allows the child to speak freely without fear of repercussions. This approach promotes trust between the nurse and the child, enabling a comprehensive and accurate assessment of their situation.

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Question 16 :Select all that apply: What are the components of the nursing assessment of child abuse? (Select all that apply).

A. Psychological evaluation of the caregiver. B. Collecting subjective and objective data. C. Assessing the child's developmental milestones. D. History-taking from the child only. E. Ensuring the child's consent and comfort.

Explanation

Choice A rationale:

Psychological evaluation of the caregiver - This choice is not typically a component of the nursing assessment of child abuse. While understanding the caregiver's psychological state can be important, the focus of the assessment is primarily on the child's well-being and safety.

Choice B rationale:

Collecting subjective and objective data - This is a crucial component of the nursing assessment for child abuse. Gathering both subjective information and objective data (physical examination findings, lab tests) helps in forming a comprehensive understanding of the situation and aids in making informed decisions.

Choice C rationale:

Assessing the child's developmental milestones - This is important because assessing the child's developmental milestones can provide valuable insights into their overall well-being and potential developmental delays. Abuse can have a significant impact on a child's development, so this assessment helps in identifying any concerns.

Choice D rationale:

History-taking from the child only - While taking history from the child is important, it's not the only source of information. Children might be hesitant to disclose abuse directly, and relying solely on their history might miss crucial information. Involving caregivers, witnesses, and other professionals is essential for a comprehensive assessment.

Choice E rationale:

Ensuring the child's consent and comfort - This is a critical aspect of the assessment. Ensuring the child's consent and comfort builds trust and promotes effective communication. It allows the child to feel safe and more likely to share important information about their situation.

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Question 17 :A nurse is assessing a child who presents with bruises in various stages of healing on the back, buttocks, and arms. The nurse should suspect which type of abuse based on these findings?

A. Emotional abuse. B. Neglect. C. Sexual abuse. D. Physical abuse.

Explanation

Choice A rationale:

Emotional abuse - This type of abuse is primarily psychological and doesn't usually involve physical signs like bruises. Emotional abuse can cause emotional and behavioral changes in children, but bruises are not indicative of emotional abuse.

Choice B rationale:

Neglect - Neglect often involves failure to provide for a child's basic needs, such as food, shelter, clothing, and medical care. While neglect can lead to various health issues, bruises in different stages of healing suggest physical harm, which is not the primary characteristic of neglect.

Choice C rationale:

Sexual abuse - Sexual abuse can cause physical and psychological harm, but bruises on various parts of the body are not specific indicators of sexual abuse. Sexual abuse signs usually involve genital or anal trauma, behavioral changes, or specific symptoms related to the abuse.

Choice D rationale:

Physical abuse - Bruises in various stages of healing on different body parts are consistent with physical abuse. These bruises raise concerns about intentional harm, and their presence suggests the child has been subjected to physical violence or injury.

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Question 18 :Select all that apply: A nurse is educating a group of parents about child abuse prevention. What primary prevention strategies should the nurse include in the teaching? (Select all that apply).

A. Stress management techniques. B. Conflict resolution skills. C. Substance use prevention strategies. D. Providing home visits to at-risk families. E. Teaching appropriate use of weapons.

Explanation

Choice A rationale:

Stress management techniques - Teaching parents stress management techniques can help them cope with challenging situations without resorting to abusive behaviors. Reducing parental stress can contribute to a healthier parent-child relationship.

Choice B rationale:

Conflict resolution skills - Teaching parents effective ways to manage conflicts without resorting to violence models healthy behavior for children. It also reduces the likelihood of aggressive behavior in the family environment.

Choice C rationale:

Substance use prevention strategies - Substance abuse can impair judgment and increase the risk of abusive behavior. Educating parents about substance use prevention helps create a safer home environment for children.

Choice D rationale:

Providing home visits to at-risk families - While home visits can be important for assessing and supporting families, they are not considered a primary prevention strategy. Home visits are more aligned with secondary prevention efforts, aimed at identifying and addressing existing issues.

Choice E rationale:

Teaching appropriate use of weapons - This choice is not a primary prevention strategy for child abuse. In fact, promoting weapon use education could potentially introduce more risks into the household environment. It's important to focus on non-violent strategies for conflict resolution and child safety.

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Question 19 :A nurse is conducting a nursing assessment on a child suspected of being a victim of abuse. Which statement by the nurse would facilitate effective communication?

A. "Why did this happen to you?” B. "Did your parents hurt you?” C. "Can you tell me what happened?” D. "You must be feeling scared, right?”

Explanation

"Can you tell me what happened?"

Choice A rationale:

"Why did this happen to you?" - This choice places blame on the child and implies that they may have done something to cause the abuse. This approach is not empathetic and can hinder effective communication.

Choice B rationale:

"Did your parents hurt you?" - This choice assumes the cause of the abuse and uses a closed-ended question, which may not encourage the child to open up. It's essential to provide an open and safe space for the child to share their experiences.

Choice C rationale:

"Can you tell me what happened?" - This choice is open-ended and non-judgmental, encouraging the child to share their perspective at their own pace. It demonstrates empathy and a willingness to listen, fostering effective communication and building trust.

Choice D rationale:

"You must be feeling scared, right?" - While acknowledging the child's emotions is important, this choice assumes the child's feelings and may not accurately reflect their emotional state. Effective communication involves allowing the child to express their feelings without leading or assuming.

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Question 20 :During a nursing assessment, a child shows signs of fear, withdrawal, and difficulty expressing emotions. Which statement by the child supports the suspicion of emotional abuse?

A. "My parents hit me sometimes.” B. "I don't feel safe at home.” C. "I can't make any friends.” D. "Nobody cares about me.”

Explanation

"I don't feel safe at home."

Choice A rationale:

"My parents hit me sometimes." - Physical abuse is indicated in this statement, not emotional abuse. It's important to differentiate between the two types of abuse.

Choice B rationale:

"I don't feel safe at home." - This statement directly suggests a lack of emotional safety within the child's home environment, which aligns with signs of emotional abuse such as fear and withdrawal. It provides insight into the child's emotional well-being.

Choice C rationale:

"I can't make any friends." - While difficulty in forming friendships can be indicative of emotional issues, it's not specific enough to confirm emotional abuse. This statement could also arise from various other factors.

Choice D rationale:

"Nobody cares about me." - This statement does suggest emotional distress, but it's not as directly tied to emotional abuse as Choice B. It could potentially indicate other emotional issues or self-esteem problems.

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Question 21 :A nurse is evaluating the outcomes of care for a child who has experienced abuse. Which outcome indicates a positive response to intervention?

A. The child avoids expressing emotions. B. The child's injuries remain unchanged. C. The child demonstrates improved social skills. D. The child reports occasional suicidal thoughts.

Explanation

"The child demonstrates improved social skills."

Choice A rationale:

"The child avoids expressing emotions." - This outcome suggests emotional suppression, which is not a positive response to intervention. Encouraging a child to express their emotions in a healthy way is essential.

Choice B rationale:

"The child's injuries remain unchanged." - This outcome focuses on physical aspects and doesn't necessarily reflect the effectiveness of interventions addressing the emotional impact of abuse.

Choice C rationale:

"The child demonstrates improved social skills." - This outcome indicates progress in the child's emotional well-being and ability to interact positively with others. Improved social skills suggest that the child is developing coping mechanisms and support systems.

Choice D rationale:

"The child reports occasional suicidal thoughts." - While this choice could reflect that the child is opening up about their feelings, it also indicates ongoing emotional distress. Positive response to intervention involves improvements in overall well-being rather than just occasional thoughts of self-harm.

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Question 22 :What is the main objective of nursing interventions for child abuse?

A. Isolating the child from the family. B. Punishing the abusers severely. C. Reporting every suspected case to the authorities. D. Protecting the child, promoting safety, and supporting healing.

Explanation

Choice A rationale:

Isolating the child from the family is not the main objective of nursing interventions for child abuse. It may exacerbate the emotional trauma that the child is already experiencing by removing them from a potentially supportive environment.

Choice B rationale:

Punishing the abusers severely, while important from a legal perspective, is not the primary focus of nursing interventions. The main goal is to ensure the safety and well-being of the child and provide them with the necessary support.

Choice C rationale:

Reporting every suspected case to the authorities is an important step in addressing child abuse, but it is not the sole objective of nursing interventions. The broader focus is on the child's safety and recovery.

Choice D rationale:

The correct answer. Nursing interventions for child abuse are primarily aimed at protecting the child from further harm, promoting their safety within their family or a suitable environment, and providing the necessary support to aid in their healing process. This approach acknowledges the psychological and emotional needs of the child while addressing the physical aspects of abuse.

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Question 23 :A nurse is assessing a child with suspected abuse. Which factor is essential during the nursing assessment of child abuse?

Explanation

Choice A rationale:

Using leading and suggestive questions should be avoided during the nursing assessment of child abuse. These types of questions can influence the child's responses and potentially compromise the accuracy of the information gathered.

Choice B rationale:

Conducting the assessment in a public place is not ideal as it can lead to discomfort for the child and inhibit open communication. Privacy is crucial to create a safe space where the child can share their experiences without fear.

Choice C rationale:

Involving the child's peers in the assessment process might not be appropriate, as discussing potential abuse in the presence of peers could cause embarrassment or pressure the child to withhold information.

Choice D rationale:

The correct answer. Performing the assessment in a safe and private environment is essential to ensure that the child feels comfortable and secure while discussing their experiences of abuse. This setting encourages honest communication and allows the nurse to gather accurate information.

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Question 24 :Select all that apply: . What are the components of the nursing assessment of child abuse? (Select all that apply).

Explanation

Choice A rationale:

Psychological evaluation of the caregiver can provide valuable insights, but it is not a core component of the nursing assessment of child abuse. The focus should be on the child's well-being and safety.

Choice B rationale:

The correct answer. Collecting subjective and objective data is crucial for a comprehensive assessment. This includes gathering information about the child's physical and emotional state, as well as the circumstances surrounding the suspected abuse.

Choice C rationale:

The correct answer. Assessing the child's developmental milestones is important because it helps identify potential delays or regressions that could indicate abuse. Monitoring developmental progress can provide valuable information about the child's overall well-being.

Choice D rationale:

History-taking from the child only is not sufficient. It's important to gather information from various sources, including caregivers and any other relevant individuals involved in the child's life.

Choice E rationale:

The correct answer. Ensuring the child's consent and comfort is essential to establish trust and facilitate open communication during the assessment process. Children should feel safe and respected throughout the evaluation.

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Elder Abuse

Question 25 :A nurse is conducting an assessment on an older adult who has been exhibiting signs of emotional distress and withdrawal. The nurse should prioritize which component of the assessment?

A. Physical examination. B. Laboratory tests. C. Diagnostic tests. D. History.

Explanation

History.

Choice A rationale:

Prioritizing the physical examination might be essential in many cases, but emotional distress and withdrawal are primarily related to psychological and emotional aspects rather than solely physical issues. A physical examination might not provide the depth of information needed to understand the underlying emotional concerns.

Choice B rationale:

Laboratory tests are unlikely to reveal insights into emotional distress and withdrawal. These signs are subjective and behavioral in nature, not typically indicated by abnormalities in lab results.

Choice C rationale:

Diagnostic tests, like laboratory tests, are more focused on identifying physiological abnormalities or specific medical conditions. They are unlikely to provide information about emotional distress and withdrawal.

Choice D rationale:

History-taking is the most relevant component to prioritize in this scenario. Older adults may have complex psychosocial factors contributing to emotional distress, such as loss of loved ones, social isolation, or recent life changes. Gathering a comprehensive history can uncover these underlying issues and provide context for the emotional changes observed.

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Question 26 :(Select all that apply): A nurse is educating a group of caregivers about elder abuse prevention. Which interventions should the nurse include in the teaching? Select all that apply.

A. Providing education on financial management. B. Promoting regular medical check-ups. C. Encouraging the use of physical restraints. D. Recommending isolation for safety. E. Offering counseling and support groups.

Explanation

Choice A:

Providing education on financial management,

Choice B:

Promoting regular medical check-ups, and Choice E:

Offering counseling and support groups.

Choice A rationale:

Educating caregivers about financial management is important because financial exploitation is a common form of elder abuse. Teaching them to safeguard finances helps protect vulnerable older adults.

Choice B rationale:

Regular medical check-ups are crucial as they enable early detection of any physical or emotional signs of abuse. This can also foster trust between the caregiver and the healthcare team.

Choice C rationale:

Encouraging the use of physical restraints is inappropriate as it violates an individual's rights and dignity, potentially leading to abuse or neglect.

Choice D rationale:

Recommending isolation for safety is not advisable. Isolation can worsen emotional distress and increase vulnerability to abuse. Maintaining social connections is important for mental well-being.

Choice E rationale:

Offering counseling and support groups can help caregivers and older adults cope with stressors and address potential abuse situations. Emotional support is crucial for maintaining mental health and preventing abuse.

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Question 27 :A nurse suspects elder abuse in a patient and asks, "Has anyone been hurting you or making you feel afraid?" The patient responds, "No, everything is fine." What should the nurse do next?

A. Document the patient's response and continue with the assessment. B. Reiterate the question with more emphasis on the importance of honesty. C. Respect the patient's denial and move on to other assessment areas. D. Request the presence of a family member before continuing the assessment.

Explanation

Document the patient's response and continue with the assessment.

Choice A rationale:

Documenting the patient's response is essential for accurate record-keeping and communication among the healthcare team. The nurse should continue with the assessment while remaining vigilant for any inconsistencies or signs of abuse that may arise later.

Choice B rationale:

Reiterating the question with more emphasis on honesty might come across as pressuring the patient to disclose abuse. This could make the patient uncomfortable and less likely to share information.

Choice C rationale:

While it's important to respect the patient's denial, elder abuse is often underreported due to fear, dependence, or manipulation. Therefore, it's crucial to continue the assessment while observing for other indicators of abuse.

Choice D rationale:

Requesting the presence of a family member before continuing the assessment could potentially escalate the situation if the family member is involved in the abuse. This action may compromise the patient's safety and comfort.

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Question 28 :A patient confides in a nurse, saying, "My caregiver threatens to kick me out of the house if I complain about anything." What should the nurse's response be?

A. "I'm sure they're just frustrated. Try to be more understanding.” B. "Let's discuss options for getting you the support you need.” C. "Maybe you should try to do more to avoid conflicts.” D. "Just ignore those threats; they don't mean anything.”

Explanation

Choice A rationale:

"I'm sure they're just frustrated. Try to be more understanding." This choice is not appropriate as it downplays the seriousness of the situation and implies that the patient should tolerate the threats. The patient's safety and well-being are the nurse's priority.

Choice B rationale:

"Let's discuss options for getting you the support you need." This is the correct response. It acknowledges the patient's concerns and offers to explore solutions together. It shows empathy and a commitment to helping the patient find a way to address the abusive situation.

Choice C rationale:

"Maybe you should try to do more to avoid conflicts." This response places blame on the patient and implies that they are responsible for the abuse. It ignores the fact that abuse is not the patient's fault and shifts the responsibility away from the caregiver who is behaving abusively.

Choice D rationale:

"Just ignore those threats; they don't mean anything." This response minimizes the threats and dismisses the patient's feelings. Ignoring threats can escalate the situation and put the patient at further risk.

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Question 29 :A nurse is assessing an older adult who has several unexplained bruises, burns, and scars in various stages of healing. The patient seems reluctant to discuss these injuries. Which nursing intervention should the nurse prioritize?

A. Reporting the suspected abuse to appropriate authorities. B. Assuring the patient that everything will be kept confidential. C. Encouraging the patient to confront the suspected abuser. D. Documenting the injuries without further investigation.

Explanation

Choice A rationale:

"Reporting the suspected abuse to appropriate authorities." This is the priority action. The nurse has an ethical and legal obligation to protect the patient's safety. Suspicion of abuse must be reported to safeguard the patient from further harm.

Choice B rationale:

"Assuring the patient that everything will be kept confidential." While confidentiality is important, it should not override the need to protect the patient's safety. Reporting suspected abuse takes precedence over maintaining confidentiality in this situation.

Choice C rationale:

"Encouraging the patient to confront the suspected abuser." Directly confronting the suspected abuser could potentially escalate the situation and jeopardize the patient's safety. Reporting to authorities is a more appropriate course of action.

Choice D rationale:

"Documenting the injuries without further investigation." Documenting injuries is important for the patient's medical record, but it does not address the immediate safety concern. Reporting the abuse is essential to ensure proper intervention.

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Question 30 :: A client has been diagnosed with elder abuse. What should the nurse assess to determine the impact of the abuse on the client's mental and emotional health?

A. Cognitive function and personality traits. B. Financial status and property ownership. C. Social support and involvement in community activities. D. Use of assistive devices and mobility aids.

Explanation

Choice A rationale:

"Cognitive function and personality traits." Elder abuse can have significant psychological effects. Assessing cognitive function and personality traits helps identify changes that may indicate emotional distress or mental health issues resulting from abuse.

Choice B rationale:

"Financial status and property ownership." While financial abuse is a concern, this choice focuses primarily on the material aspect of abuse. Mental and emotional impact on the client's health is a higher priority in this context.

Choice C rationale:

"Social support and involvement in community activities." While social support is important, it is not the primary indicator of the impact of abuse on mental and emotional health. The effects of abuse may manifest even if the client has a supportive social network.

Choice D rationale:

"Use of assistive devices and mobility aids." Assistive devices and mobility aids are relevant to physical health, not the mental and emotional impact of abuse. Mental health assessment is more relevant in this context.

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Question 31 :: A nurse is planning care for an older adult who has experienced elder abuse. Which intervention is a priority in the care plan?

A. Providing education to the client about legal rights. B. Arranging for the client to move into a long-term care facility. C. Encouraging the client to confront the abuser about the abuse. D. Developing a safety plan for the client to prevent further abuse.

Explanation

Choice A rationale:

Providing education to the client about legal rights (Choice A) is important, but it might not immediately address the safety concerns of the older adult who has already experienced elder abuse. Legal education should be a part of the care plan, but safety takes precedence.

Choice B rationale:

Arranging for the client to move into a long-term care facility (Choice B) might be an option if the client's safety cannot be ensured at their current location. However, moving into a new facility can be overwhelming and might not be the most immediate priority. Developing a safety plan can help address the abuse concerns directly.

Choice C rationale:

Encouraging the client to confront the abuser about the abuse (Choice C) could potentially escalate the situation and put the client at risk of further harm. This choice may not ensure the client's safety, which is the primary concern.

Choice D rationale:

Developing a safety plan for the client to prevent further abuse (Choice D) is the priority intervention. This choice ensures that immediate measures are taken to protect the client from further harm. A safety plan might involve assessing the client's environment, identifying potential risks, providing resources for emergency situations, and connecting the client with support services.

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Question 32 :: A nurse is assessing an older adult for potential signs of neglect. Which finding would be most concerning?

A. Unexplained bruises on the arms. B. A decline in cognitive function. C. Inadequate food in the refrigerator. D. Isolation from family and friends.

Explanation

Choice A rationale:

Unexplained bruises on the arms (Choice A) are concerning and might indicate physical abuse. However, bruises can sometimes occur due to accidental causes, so while this finding is important, it might not be as indicative of neglect as inadequate food.

Choice B rationale:

A decline in cognitive function (Choice B) is a common issue among older adults but might not necessarily be linked to neglect. It could be due to various factors such as aging or underlying health conditions.

Choice C rationale:

Inadequate food in the refrigerator (Choice C) is the most concerning finding among the options provided. It suggests that the older adult might not be receiving proper nutrition, which can have serious health implications. Neglecting basic needs like food raises significant alarms.

Choice D rationale:

Isolation from family and friends (Choice D) is a potential sign of neglect or abuse, as social isolation can contribute to a decline in overall well-being. However, it might not pose an immediate threat to health in the same way as inadequate food.

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Post-Traumatic Stress Disorder (PTSD)

Question 33 :A nurse is assessing a client who has experienced a traumatic event. Which of the following would be considered a traumatic event according to the text?

A. Taking a vacation. B. Changing jobs. C. Experiencing a natural disaster. D. Celebrating a birthday.

Explanation

Choice A rationale:

Taking a vacation (Choice A) might be enjoyable or stressful depending on the circumstances, but it is not generally considered a traumatic event as it does not involve a threat to one's physical or psychological well-being.

Choice B rationale:

Changing jobs (Choice B) is a significant life event, but it is not inherently a traumatic event. It can be a positive or negative experience, depending on the individual's perspective.

Choice C rationale:

Experiencing a natural disaster (Choice C) is a traumatic event according to the text. Natural disasters can result in life-threatening situations, loss of property, and psychological distress, potentially leading to long-lasting effects on mental health.

Choice D rationale:

Celebrating a birthday (Choice D) is a joyful occasion and is not considered a traumatic event. It typically brings positive emotions and does not involve exposure to harm or danger.

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Question 34 :A nurse is educating a group of individuals about trauma and its effects. Which of the following statements accurately describe traumatic events? Select all that apply.

A. Traumatic events can involve serious injuries. B. Traumatic events only include natural disasters. C. Traumatic events can lead to mental disorders. D. Traumatic events can have long-lasting consequences. E. Traumatic events only affect certain age groups.

Explanation

Choice A rationale:

Traumatic events can involve serious injuries. This choice accurately reflects that traumatic events can encompass a wide range of situations that result in physical harm, such as accidents, violence, or medical emergencies. These events can lead to significant injuries and medical consequences.

Choice C rationale:

Traumatic events can lead to mental disorders. This choice is correct because traumatic experiences can indeed trigger the development of mental health conditions such as post-traumatic stress disorder (PTSD), depression, anxiety disorders, and more. The emotional impact of trauma can have lasting effects on a person's psychological well-being.

Choice D rationale:

Traumatic events can have long-lasting consequences. This choice is accurate as traumatic events can leave enduring impacts on individuals, affecting their mental, emotional, and physical well-being over an extended period. These consequences can range from chronic psychological distress to changes in behavior and relationships. Now, let's address the incorrect choices:

Choice B rationale:

Traumatic events only include natural disasters. This choice is incorrect because traumatic events are not limited to natural disasters alone. Trauma can result from various experiences, including accidents, violence, abuse, and more. Natural disasters are just one category of traumatic events.

Choice E rationale:

Traumatic events only affect certain age groups. This choice is also incorrect. Traumatic events can affect people of all ages, from children to the elderly. The impact of trauma is not restricted by age; it can influence anyone who experiences or witnesses a distressing event.

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Question 35 :A nurse is caring for a client with post-traumatic stress disorder (PTSD). The client states, "I keep having nightmares about the accident and I can't get them out of my head." This statement is an example of which symptom cluster of PTSD?

A. Intrusion symptoms. B. Avoidance symptoms. C. Negative alterations in cognition and mood. D. Alterations in arousal and reactivity.

Explanation

Choice A rationale:

Intrusion symptoms. This choice is accurate because the client's statement about recurring nightmares and intrusive thoughts related to the accident aligns with the intrusion symptoms of post-traumatic stress disorder (PTSD). Intrusion symptoms involve distressing memories, nightmares, and flashbacks that "intrude" into the person's consciousness. Now, let's address the other choices:

Choice B rationale:

Avoidance symptoms. This choice is incorrect for this scenario. Avoidance symptoms in PTSD involve efforts to avoid reminders, thoughts, or situations associated with the traumatic event. The client's statement does not specifically reflect avoidance behaviors.

Choice C rationale:

Negative alterations in cognition and mood. This choice is also incorrect in this context. Negative alterations in cognition and mood include feelings of detachment, negative beliefs, and distorted emotions. The client's statement does not directly relate to these alterations.

Choice D rationale:

Alterations in arousal and reactivity. This choice is incorrect for the given statement. Alterations in arousal and reactivity involve symptoms like irritability, hypervigilance, and exaggerated startle response. The client's description of recurring nightmares and intrusive thoughts does not align with this symptom cluster.

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Question 36 :A nurse is providing care to a client with PTSD. The client avoids going to the site where the traumatic event occurred. This behavior is an example of which symptom cluster of PTSD?

A. Intrusion symptoms. B. Avoidance symptoms. C. Negative alterations in cognition and mood. D. Alterations in arousal and reactivity.

Explanation

Choice B rationale:

Avoidance symptoms. This choice is accurate because the client's behavior of avoiding the site where the traumatic event occurred is characteristic of avoidance symptoms in PTSD. People with PTSD often go to great lengths to avoid reminders and triggers associated with the trauma. Now, let's address the other choices:

Choice A rationale:

Intrusion symptoms. This choice is incorrect in this context. Intrusion symptoms involve unwanted memories, nightmares, and flashbacks that intrude into a person's consciousness. Avoiding the site of the traumatic event does not align with this symptom cluster.

Choice C rationale:

Negative alterations in cognition and mood. This choice is not applicable to the client's behavior described. Negative alterations in cognition and mood involve feelings of detachment, distorted emotions, and negative beliefs about oneself or the world. Avoiding a specific location does not directly relate to this cluster.

Choice D rationale:

Alterations in arousal and reactivity. This choice is also incorrect for the given behavior. Alterations in arousal and reactivity include symptoms like irritability, hypervigilance, and difficulty concentrating. Avoidance of a particular site is not directly related to this symptom cluster.

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Question 37 :A client who experienced a traumatic event presents with physical symptoms such as headaches and chronic pain. These symptoms can be attributed to which clinical manifestation of PTSD?

A. Psychological signs. B. Emotional signs. C. Physical signs. D. Social signs.

Explanation

Physical signs.

Choice A rationale:

Psychological signs involve cognitive and mental aspects of PTSD, such as flashbacks and intrusive thoughts.

Choice B rationale:

Emotional signs encompass mood-related manifestations like fear, anger, and guilt.

Choice D rationale:

Social signs refer to difficulties in interpersonal relationships and isolation. In contrast, Choice C, physical signs, include symptoms like headaches and chronic pain which are commonly associated with PTSD due to the physiological stress response triggered by the traumatic event. This response can lead to increased muscle tension and altered pain perception, resulting in these physical symptoms. Such somatic complaints are integral to the diagnosis of PTSD, and they often coexist with other psychological and emotional symptoms.

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Question 38 :

A nurse is assessing a client for potential PTSD symptoms. Which statement by the client indicates they are experiencing intrusion symptoms?

A. "I've been feeling really detached from everyone lately.” B. "I keep having nightmares about the accident.” C. "I can't seem to stop thinking about what happened.” D. "I've been feeling very irritable and on edge.”

Explanation

"I keep having nightmares about the accident."

Choice A rationale:

Feeling detached from others is a characteristic of the numbing/avoidance cluster of PTSD symptoms, not intrusion symptoms.

Choice C rationale:

Involuntary, distressing thoughts about the traumatic event are indicative of intrusion symptoms, which are encapsulated by Choice B.

Choice D rationale:

Feeling irritable and on edge falls under the hyperarousal symptom category. Choice B, the correct choice, relates to nightmares about the traumatic incident, a classic intrusion symptom. These nightmares can re-traumatize the individual, making sleep challenging and contributing to the overall distress associated with PTSD.

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Question 39 :

A nurse is planning care for a client with PTSD. Which intervention is appropriate for addressing avoidance symptoms?

A. Encouraging the client to engage in relaxation techniques. B. Providing the client with information about local support groups. C. Teaching the client cognitive-behavioral techniques. D. Administering prescribed medications to manage anxiety.

Explanation

Providing the client with information about local support groups.

Choice A rationale:

Encouraging relaxation techniques targets symptom management but doesn't directly address avoidance symptoms.

Choice C rationale:

Cognitive-behavioral techniques are helpful for various PTSD symptoms, but they primarily focus on modifying thought patterns and behaviors.

Choice D rationale:

Medications can alleviate symptoms like anxiety but don't specifically tackle avoidance symptoms. In contrast, Choice B is the most suitable intervention for addressing avoidance symptoms. Individuals with PTSD often avoid situations, places, or people that trigger memories of the trauma. Connecting them with local support groups can provide a safe environment to discuss their experiences, gradually reducing avoidance behavior. Peer support can offer validation, normalization, and sharing of coping strategies, which can ultimately aid in diminishing avoidance symptoms.

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Question 40 :

A client with PTSD is experiencing alterations in arousal and reactivity. Which nursing intervention would be most appropriate for this symptom cluster?

A. Assisting the client in identifying and challenging negative thoughts. B. Encouraging the client to discuss their traumatic experience in detail. C. Teaching the client grounding techniques to manage anxiety. D. Providing the client with a list of community resources for support.

Explanation

Choice A rationale:

Assisting the client in identifying and challenging negative thoughts might be more appropriate for addressing cognitive distortions in conditions like depression or anxiety disorders, but it might not directly address the alterations in arousal and reactivity characteristic of PTSD.

Choice B rationale:

Encouraging the client to discuss their traumatic experience in detail could potentially trigger retraumatization and exacerbate the symptoms. Exposure therapy, which involves discussing the trauma, is generally done in a controlled and gradual manner under the guidance of a therapist.

Choice C rationale:

Teaching the client grounding techniques to manage anxiety is the most appropriate option. Grounding techniques help individuals stay connected to the present moment, reduce feelings of detachment, and manage anxiety. Techniques might include deep breathing, mindfulness, or using sensory cues to anchor oneself.

Choice D rationale:

Providing the client with a list of community resources for support is important, but it does not directly address the specific symptom cluster of alterations in arousal and reactivity. This intervention might be more relevant for overall support and coping, but not for managing the specific symptoms mentioned.

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Question 41 :

A nurse is assessing a client who experienced a traumatic event one week ago. The client is unable to remember important aspects of the event and reports feeling detached from their surroundings. Which symptom is the nurse observing in this client?

A. Intrusive memories. B. Negative mood. C. Dissociation. D. Avoidance. E. Arousal.

Explanation

Choice A rationale:

Intrusive memories are characterized by the sudden and distressing re-experiencing of the traumatic event. These memories can be in the form of flashbacks or nightmares and are not directly related to the client's reported inability to remember aspects of the event and feeling detached.

Choice B rationale:

Negative mood, while common in PTSD, pertains to feelings of sadness, anger, or guilt. It is not the primary symptom described in this scenario, where the client is struggling with memory gaps and detachment.

Choice C rationale:

The nurse is observing dissociation in this client. Dissociation involves feeling disconnected from oneself or the environment, often as a defense mechanism in response to trauma. This can manifest as depersonalization (feeling detached from one's own body) or derealization (feeling detached from one's surroundings).

Choice D rationale:

Avoidance refers to the avoidance of reminders or situations associated with the traumatic event. While it can be a symptom of PTSD, it doesn't fully capture the reported memory issues and detachment observed in this client.

Choice E rationale:

Arousal symptoms involve heightened physiological responses such as hypervigilance, irritability, and exaggerated startle responses. These symptoms are not the primary focus of the scenario, which is centered around memory gaps and detachment.

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Question 42 :

(Select all that apply): A nurse is conducting an assessment of a client with acute stress disorder (ASD). Which physical signs might the nurse find in the client?

A. Gastrointestinal problems. B. Cardiovascular problems. C. Chronic pain. D. Substance use disorder. E. Eating disorders.

Explanation

Choice A rationale:

Gastrointestinal problems, such as nausea, vomiting, and diarrhea, can be physical signs of acute stress disorder. The stress response can impact the gastrointestinal system due to the activation of the "fight or flight" response.

Choice B rationale:

Cardiovascular problems, such as increased heart rate and blood pressure, are also common physical signs of acute stress disorder. The body's physiological response to stress can lead to cardiovascular changes.

Choice C rationale:

Chronic pain is not typically considered a primary physical sign of acute stress disorder. While stress can exacerbate existing pain conditions, it is not among the hallmark physical symptoms of this disorder.

Choice D rationale:

Substance use disorder might develop as a maladaptive coping mechanism in response to stress, but it is not a direct physical sign that a nurse would observe upon assessment.

Choice E rationale:

Eating disorders are not typically considered a primary physical sign of acute stress disorder. While stress can affect eating habits, it is not one of the characteristic physical symptoms associated with this disorder.

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Acute Stress Disorder (ASD)

Question 43 :A nurse is providing education to a client with acute stress disorder (ASD). The client states, "I can't experience happiness anymore." Which nursing response is appropriate?

A. "It's normal to feel that way after a traumatic event.” B. "You'll get over this eventually; just give it time.” C. "You should focus on avoiding situations that remind you of the trauma.” D. "Try to forget about the event completely and move on.”

Explanation

Choice A rationale:

The nurse's response of acknowledging the client's emotions and normalizing their feelings validates their experience. It emphasizes that such emotional responses are common after traumatic events, helping to reduce the client's distress and potentially fostering a sense of connection.

Choice B rationale:

This response might invalidate the client's emotions and rush their healing process. Telling the client that they will "get over this eventually" oversimplifies their experience and may cause further frustration.

Choice C rationale:

Advising the client to solely focus on avoiding reminders of the trauma (situations that remind them of the event) could lead to avoidance behaviors and hinder their recovery. It's important to gradually address triggers rather than completely avoiding them.

Choice D rationale:

Encouraging the client to "forget about the event completely and move on" could be dismissive of their emotional struggle. Forgetting is not a realistic goal, and suppressing emotions can be harmful in the long run.

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Question 44 :A client with acute stress disorder (ASD) tells the nurse, "I can't go near the place where the event happened." What is the nurse's best response?

A. "You should face your fears and confront that place.” B. "Avoiding the place is a good way to prevent triggering your symptoms.” C. "It's important to gradually expose yourself to that place to overcome your fear.” D. "Let's explore some ways to cope with your feelings of distress when thinking about that place.”

Explanation

Choice A rationale:

Urging the client to "face their fears and confront that place" might overwhelm them and exacerbate their distress. Gradual exposure is a more effective approach in managing anxiety related to trauma.

Choice B rationale:

While avoidance might provide temporary relief, it reinforces the fear and prevents the client from processing the traumatic memory. Encouraging avoidance can contribute to the persistence of their symptoms.

Choice C rationale:

Gradual exposure is indeed a recommended therapeutic technique, but directly telling the client to "gradually expose themselves" might not be well received. Collaboration and guidance are important in this process.

Choice D rationale:

This response acknowledges the client's distress and suggests a collaborative approach to coping with their feelings. It opens the door for discussing coping strategies and potentially seeking professional help.

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Question 45 :A nurse is planning interventions for a client with acute stress disorder (ASD). Which nursing intervention aims to protect the individual's rights and promote safety?

A. Administering psychological tests. B. Providing education about trauma prevention. C. Referring the individual to appropriate services. D. Implementing primary, secondary, and tertiary prevention strategies. E. Ensuring the individual's privacy and dignity are respected.

Explanation

Choice A rationale:

Administering psychological tests is not directly related to protecting the individual's rights and promoting safety. While assessment is important, it's not a primary intervention for safeguarding rights or safety.

Choice B rationale:

Providing education about trauma prevention is valuable, but it doesn't specifically address protecting the individual's rights or ensuring their safety after the traumatic event.

Choice C rationale:

Referring the individual to appropriate services, such as therapy or counseling, can help address their emotional and psychological needs while respecting their rights. This is crucial in promoting their well-being.

Choice D rationale:

Implementing prevention strategies is essential for public health but is not the primary focus when dealing with an individual already diagnosed with acute stress disorder (ASD).

Choice E rationale:

Respecting the individual's privacy and dignity creates a therapeutic and safe environment. Trauma can make individuals feel vulnerable, and ensuring their dignity is upheld helps build trust in the therapeutic relationship.

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Question 46 :

Which assessment finding should the nurse expect in a client with acute stress disorder (ASD)?

A. Inability to remember details of the traumatic event. B. A stable heart rate and blood pressure. C. Euphoric mood and increased energy. D. Hyperactivity and distractibility.

Explanation

Choice A rationale:

Clients with acute stress disorder (ASD) often experience dissociation, which can lead to an inability to remember crucial details of the traumatic event. This is known as dissociative amnesia and is a hallmark symptom of ASD. The traumatic event is typically encoded in fragmented or incomplete memories due to the intense stress and emotional impact it carries.

Choice B rationale:

A stable heart rate and blood pressure (Choice B) are not typical findings in clients with acute stress disorder. ASD is characterized by an acute stress response, which often leads to physiological changes such as increased heart rate and blood pressure, not stability.

Choice C rationale:

Euphoric mood and increased energy (Choice C) are not consistent with the symptoms of acute stress disorder. ASD is more likely to cause mood disturbances like anxiety, hypervigilance, and irritability, rather than euphoria and increased energy.

Choice D rationale:

Hyperactivity and distractibility (Choice D) are not primary symptoms of acute stress disorder. While heightened arousal can occur in response to stress, hyperactivity and distractibility are more indicative of conditions like attention-deficit/hyperactivity disorder (ADHD) rather than ASD.

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Question 47 :

A nurse is caring for a client with acute stress disorder (ASD). Which intervention is the nurse's priority during the acute phase of the disorder?

A. Encouraging the client to talk about the traumatic event. B. Administering antianxiety medication as prescribed. C. Assisting the client in identifying triggers for anxiety. D. Providing education about relaxation techniques.

Explanation

Choice B rationale:

Administering antianxiety medication as prescribed is the nurse's priority during the acute phase of acute stress disorder (ASD). This is because individuals with ASD often experience severe anxiety, panic attacks, and overwhelming distress. Antianxiety medications, such as benzodiazepines, can help manage the acute symptoms and provide relief from extreme anxiety.

Choice A rationale:

Encouraging the client to talk about the traumatic event (Choice A) might not be the priority during the acute phase. Revisiting the traumatic event prematurely could potentially retraumatize the client and exacerbate their symptoms.

Choice C rationale:

Assisting the client in identifying triggers for anxiety (Choice C) is an important intervention, but it may be more relevant during the later stages of treatment, when the client is more stabilized and ready to engage in cognitive-behavioral interventions.

Choice D rationale:

Providing education about relaxation techniques (Choice D) is valuable, but it might not be the top priority during the acute phase. The client's distress and anxiety levels are likely to be too high to effectively engage with relaxation techniques initially.

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Question 48 :

Which statement by the client indicates a need for further education about acute stress disorder (ASD)?

A. "I can't believe I'm feeling so detached from everything.” B. "I've been avoiding places that remind me of the trauma.” C. "I'm so relieved that my symptoms will go away within a few days.” D. "I've been having nightmares about the event.”

Explanation

Choice C rationale:

The statement "I'm so relieved that my symptoms will go away within a few days" indicates a need for further education about acute stress disorder (ASD). ASD symptoms typically last for a minimum of 3 days and can persist for up to a month. This statement suggests a misunderstanding about the duration of symptoms and the potential need for appropriate interventions.

Choice A rationale:

The statement "I can't believe I'm feeling so detached from everything" (Choice A) is consistent with the emotional numbing and detachment often experienced by individuals with ASD, and it does not indicate a need for further education.

Choice B rationale:

The statement "I've been avoiding places that remind me of the trauma" (Choice B) is in line with the avoidance symptoms of ASD and does not necessarily indicate a need for further education.

Choice D rationale:

The statement "I've been having nightmares about the event" (Choice D) is indicative of the intrusive symptoms common in ASD and does not necessarily indicate a need for further education.

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Adjustment Disorder (AD)

Question 49 :A nurse is caring for a client who has been diagnosed with adjustment disorder with depressed mood after losing his job. Which of the following interventions should the nurse include in the plan of care?

A. Encourage the client to express his feelings and concerns. B. Advise the client to avoid contact with his former coworkers. C. Suggest the client to take antidepressant medication for at least six months. D. Teach the client relaxation techniques such as deep breathing and progressive muscle relaxation.

Explanation

Choice A rationale:

Encouraging the client to express his feelings and concerns is a key intervention for someone diagnosed with adjustment disorder with depressed mood. This approach provides an outlet for the client to verbalize their emotions, which can help them process their thoughts and feelings. Through this expression, the client may gain insight into their emotional state and begin to develop healthier coping mechanisms.

Choice B rationale:

Advising the client to avoid contact with former coworkers is not an appropriate intervention. Social support is crucial during times of adjustment, and isolating oneself from supportive individuals can exacerbate feelings of depression and increase the risk of worsening mental health. Encouraging positive social interactions would be more beneficial.

Choice C rationale:

Suggesting the client take antidepressant medication for at least six months is not the primary intervention for adjustment disorder with depressed mood. Antidepressants are typically prescribed for major depressive disorder or other mood disorders. Adjustment disorder is usually managed through psychotherapy, counseling, and support rather than solely relying on medication.

Choice D rationale:

Teaching the client relaxation techniques such as deep breathing and progressive muscle relaxation is a valuable intervention, but it might not be the most effective as a standalone treatment for adjustment disorder with depressed mood. While relaxation techniques can help manage symptoms, addressing underlying emotional issues and facilitating emotional expression are more directly relevant to this disorder.

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Question 50 :A nurse is conducting a health history interview with a client who has adjustment disorder with anxiety. Which of the following questions should the nurse ask to assess the client’s coping skills? (Select all that apply.)

A. How do you usually deal with stressful situations? B. What are some of the sources of stress in your life? C. How often do you exercise or engage in physical activity? D. What are some of the goals that you have for yourself? E. How do you feel about your current situation?

Explanation

Choice A rationale:

Inquiring about the client's typical coping mechanisms provides insight into their ability to manage stressors effectively. This information helps the nurse tailor interventions and support strategies to enhance the client's coping skills.

Choice B rationale:

Identifying the sources of stress in the client's life is essential in understanding the triggers that contribute to their adjustment disorder with anxiety. Addressing these stressors can aid in developing coping strategies and reducing the impact of these stressors on the client's mental well-being.

Choice C rationale:

While physical activity and exercise can contribute to overall mental well-being, it might not be the primary focus when assessing coping skills for adjustment disorder with anxiety. The other options more directly target coping strategies and stress management.

Choice D rationale:

Exploring the client's goals can shed light on their motivations and aspirations. Having goals can positively influence a client's sense of purpose and hope, which can be integral in managing adjustment disorder with anxiety.

Choice E rationale:

While understanding the client's emotions about their current situation is important, this question may not directly assess coping skills. It's more focused on emotional self-awareness than evaluating how the client copes with stress.

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Question 51 :A nurse is providing psychoeducation to a client who has adjustment disorder with disturbance of conduct. The nurse explains that this type of adjustment disorder is characterized by which of the following behaviors?

A. “You may experience excessive worry, nervousness, or fear.” B. “You may feel sad, hopeless, or have difficulty enjoying things.” C. “You may act out, violate rules, or have problems with authority figures.” D. “You may have mixed emotions, such as anxiety and depression.”

Explanation

Choice A rationale:

Excessive worry, nervousness, or fear are characteristic of generalized anxiety disorder, not adjustment disorder with disturbance of conduct.

Choice B rationale:

Feeling sad, hopeless, or having difficulty enjoying things corresponds to symptoms of major depressive disorder, not adjustment disorder with disturbance of conduct.

Choice C rationale:

Acting out, violating rules, and having problems with authority figures are behaviors indicative of adjustment disorder with disturbance of conduct. This type of adjustment disorder involves behavioral issues and challenges in adhering to social norms and rules.

Choice D rationale:

Experiencing mixed emotions, such as anxiety and depression, is common in various mental health conditions, but it's not specific to adjustment disorder with disturbance of conduct.

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Question 52 :A nurse is evaluating the progress of a client who has adjustment disorder with mixed disturbance of emotions and conduct. The nurse determines that the client has improved when the client makes which of the following statements?

A. “I don’t care what happens to me anymore.” B. “I still miss my old life, but I’m trying to move on.” C. “I’m so angry at everyone who caused this to happen.” D. “I feel like nothing will ever change for the better.”

Explanation

Choice A rationale:

The statement "I don’t care what happens to me anymore" indicates a lack of interest or investment in one's well-being, which is not a sign of improvement in adjustment disorder. Improvement involves a more positive outlook.

Choice B rationale:

This statement reflects the client's acknowledgment of missing their old life but actively attempting to move forward. This signifies progress in dealing with the emotional and conduct disturbances often seen in adjustment disorder.

Choice C rationale:

"I’m so angry at everyone who caused this to happen" indicates ongoing anger and blame towards others, which may suggest a lack of resolution in the emotional turmoil associated with adjustment disorder. Improvement typically involves a reduction in intense negative emotions.

Choice D rationale:

"I feel like nothing will ever change for the better" represents a pessimistic and hopeless perspective, indicating that the client does not perceive any potential for improvement. This mindset does not align with progress in adjustment disorder.

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Question 53 :A nurse is reviewing the diagnostic criteria for adjustment disorder with a group of nursing students. The nurse explains that one of the criteria is that the symptoms must appear within how many months of exposure to the stressor?

A. One month B. Three months C. Six months D. Twelve months.

Explanation

Choice A rationale:

Symptoms of adjustment disorder must appear within one month of exposure to the stressor. This time frame helps differentiate adjustment disorder from other mental health conditions that might have a longer onset period, such as major depressive disorder.

Choice B rationale:

Three months is a longer period than the typical onset for symptoms of adjustment disorder. The correct time frame is within one month to establish a clear connection between the stressor and the subsequent emotional and behavioral responses.

Choice C rationale:

Six months is beyond the specified time frame for the appearance of symptoms in adjustment disorder. The shorter time frame of one month is more relevant to this diagnosis.

Choice D rationale:

Twelve months exceeds the appropriate time frame for diagnosing adjustment disorder. The focus is on the relatively short period of one month for symptoms to manifest after exposure to a stressor.

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Question 54 :A nurse is preparing a discharge plan for a client who has adjustment disorder with unspecified symptoms. Which of the following referrals should the nurse include in the plan?

A. A social worker to assist with financial and legal issues. B. A psychiatrist to prescribe and monitor psychotropic medications. C. A psychologist to provide cognitive-behavioral therapy. D. A support group to share experiences and coping strategies.

Explanation

Choice A rationale:

Including a social worker to help with financial and legal issues is important because adjustment disorder can lead to practical challenges in these areas due to the emotional and behavioral disturbances. Addressing these stressors can contribute to the client's overall well-being.

Choice B rationale:

While psychotropic medications might be used to manage certain symptoms, adjustment disorder primarily involves emotional and behavioral responses to stressors. Therefore, a psychiatrist's involvement is not the primary referral for this case.

Choice C rationale:

Cognitive-behavioral therapy (CBT) is a valuable intervention for adjustment disorder, focusing on changing maladaptive thought patterns and behaviors. However, the question specifies "unspecified symptoms," and other practical issues (financial and legal) are of greater concern at this stage.

Choice D rationale:

Joining a support group can be helpful for sharing experiences and coping strategies, but for the specific needs associated with adjustment disorder and its impact on financial and legal matters, a social worker's expertise is more relevant. 18. Correct answer: B - The client's statement reflects an effort to move on from the past. Correct answer: A - Symptoms of adjustment disorder must appear within one month of the stressor. Correct answer: A - A social worker can address practical issues arising from adjustment disorder.

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Question 55 :A nurse is assessing a client who has adjustment disorder with anxiety and depressed mood following a divorce. Which of the following findings should the nurse expect? (Select all that apply.)

A. Difficulty sleeping B. Loss of appetite C. Suicidal ideation D. Impaired concentration E. Increased energy.

Explanation

Choice A rationale:

Difficulty sleeping can be an expected finding in a client with adjustment disorder due to the heightened anxiety and stress associated with the condition. Sleep disturbances, including difficulty falling asleep, staying asleep, or experiencing restless sleep, are common manifestations. The psychological distress from the divorce can lead to disruptions in the sleep-wake cycle, impacting overall sleep quality.

Choice B rationale:

Loss of appetite is another potential symptom in clients with adjustment disorder. The emotional turmoil resulting from the divorce can cause a reduced interest in food, leading to appetite changes and subsequent weight loss. This can be attributed to the physiological and psychological impact of stress on the body.

Choice C rationale:

Suicidal ideation is not a common symptom of adjustment disorder. While clients may experience emotional distress and mood disturbances, full-blown suicidal ideation is more often associated with more severe mental health conditions like major depressive disorder or generalized anxiety disorder.

Choice D rationale:

Impaired concentration is an expected symptom in adjustment disorder. The emotional strain and anxiety related to the divorce can lead to difficulty focusing, making decisions, and maintaining attention on tasks. This cognitive impairment is a direct consequence of the psychological distress.

Choice E rationale:

Increased energy is not typically associated with adjustment disorder. Rather, clients with this condition often experience fatigue, decreased energy levels, and a lack of motivation due to the emotional toll of the stressor (in this case, the divorce).

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Question 56 :A nurse is educating a client who has adjustment disorder about stress management techniques. Which of the following statements should the nurse make? (Select all that apply.)

A. “You should try to avoid situations that trigger your stress.” B. “You should practice positive self-talk and affirmations.” C. “You should set realistic and attainable goals for yourself.” D. “You should seek social support from your friends and family.” E. “You should use alcohol or drugs to cope with your stress.”

Explanation

Choice A rationale:

Avoiding stress-triggering situations is not a comprehensive strategy for managing stress, especially for individuals with adjustment disorder. Total avoidance can hinder personal growth and does not address the underlying issues contributing to the disorder.

Choice B rationale:

Practicing positive self-talk and affirmations is an effective stress management technique. This technique helps individuals challenge negative thoughts, boost self-esteem, and develop a more optimistic outlook. This is particularly beneficial for clients with adjustment disorder to counter the negative emotions associated with their stressor.

Choice C rationale:

Setting realistic and attainable goals is an essential aspect of stress management. It provides a sense of purpose and accomplishment, contributing to improved self-esteem. For clients with adjustment disorder, achieving even small goals can enhance their sense of control and reduce feelings of helplessness.

Choice D rationale:

Seeking social support from friends and family is crucial for individuals with adjustment disorder. Positive social interactions provide emotional comfort, encouragement, and a sense of belonging, which can counteract the feelings of isolation and distress that often accompany adjustment disorder.

Choice E rationale:

Using alcohol or drugs to cope with stress is an unhealthy and counterproductive strategy. Substance use can exacerbate emotional distress, interfere with problem-solving skills, and lead to dependency. It does not address the root causes of the stress and can worsen the symptoms of adjustment disorder.

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Reactive Attachment Disorder (RAD)

Question 57 :A nurse is assessing a child with reactive attachment disorder (RAD). What are some common psychological signs of RAD?

A. Aggression and violence. B. Lack of trust and empathy. C. Growth retardation and malnutrition. D. Lack of involvement in social activities.

Explanation

Choice A rationale:

Aggression and violence are not typical psychological signs of reactive attachment disorder (RAD). RAD is characterized by difficulties forming healthy emotional attachments and relationships, rather than overt aggressive behaviors.

Choice B rationale:

Lack of trust and empathy are hallmark psychological signs of RAD. Children with RAD often struggle to establish and maintain trust in caregivers, which can lead to challenges in forming healthy relationships later in life. Additionally, impaired empathy is a common feature, as these children may not fully understand or respond to others' emotions.

Choice C rationale:

Growth retardation and malnutrition are not primarily psychological signs of RAD. While children with RAD may exhibit problems with physical growth and development due to neglect or inconsistent caregiving, these are more related to the physical aspects of care rather than psychological symptoms.

Choice D rationale:

Lack of involvement in social activities is related to RAD. Children with RAD often have difficulty participating in and enjoying social interactions due to their challenges with forming attachments and developing trust. However, this symptom is primarily related to their psychological struggles rather than a lack of interest in social activities.

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Question 58 :

(Select all that apply): A nurse is providing nursing interventions for a child with reactive attachment disorder (RAD). Which interventions are appropriate for this child?

A. Educating the child and caregiver about attachment development. B. Protecting the child's rights and ensuring a safe environment. C. Administering psychological tests for personality assessment. D. Providing legal assistance and reporting any suspected abuse.

Explanation

Choice A rationale:

Educating the child and caregiver about attachment development (Choice A) is an appropriate intervention for a child with reactive attachment disorder (RAD). This disorder is characterized by significant difficulties in forming emotional attachments due to early negative caregiving experiences. Providing education about attachment development can help both the child and caregiver understand the underlying issues and work towards building healthier attachments.

Choice B rationale:

Protecting the child's rights and ensuring a safe environment (Choice B) is crucial for children with RAD. These children often have a history of neglect or abuse, and ensuring their safety and rights is a priority to prevent further harm.

Choice C rationale:

Administering psychological tests for personality assessment (Choice C) is not a primary nursing intervention for RAD. RAD is primarily diagnosed based on clinical observations and history rather than personality assessments.

Choice D rationale:

Providing legal assistance and reporting any suspected abuse (Choice D) is important for ensuring the child's safety, but it is not a direct nursing intervention for RAD. Legal assistance and reporting abuse would be necessary if there are suspicions of maltreatment but are not specific interventions for addressing RAD.

Choice E rationale:

Referring the child to community services for physical therapy (Choice E) is not directly related to addressing the core issues of reactive attachment disorder. Physical therapy may be beneficial for certain conditions, but it's not a primary intervention for RAD.

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Question 59 :

A client diagnosed with reactive attachment disorder (RAD) states, "I feel so lonely and disconnected from others." Which response by the nurse is appropriate?

A. "It's normal to feel this way sometimes.” B. "You're just imagining these feelings.” C. "I understand. Let's talk about what you're experiencing.” D. "You should focus on making more friends.”

Explanation

Choice C rationale:

Responding with "I understand. Let's talk about what you're experiencing." (Choice C) is appropriate for a client with reactive attachment disorder who expresses feelings of loneliness and disconnection. This response demonstrates empathy, acknowledges the client's emotions, and encourages further discussion to explore their experiences.

Choice A rationale:

Responding with "It's normal to feel this way sometimes." (Choice A) might minimize the client's emotions and struggles. It's important to validate the client's feelings rather than dismissing them as normal.

Choice B rationale:

Responding with "You're just imagining these feelings." (Choice B) is invalidating and negating the client's emotions. Such a response can damage the therapeutic relationship and discourage the client from opening up further.

Choice D rationale:

Responding with "You should focus on making more friends." (Choice D) overlooks the underlying issues of reactive attachment disorder and oversimplifies the client's feelings. It does not address the core challenges that the client is facing.

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Question 60 :

A nurse is assessing a child for reactive attachment disorder (RAD). The child's caregiver reports, "They don't seem to care about anyone or anything." How should the nurse interpret this statement?

A. The child may have difficulty forming attachments. B. The child is likely a social and outgoing individual. C. The child is experiencing normal emotional development. D. The child is showing affection towards others.

Explanation

Choice A rationale:

Interpreting the caregiver's statement, "They don't seem to care about anyone or anything," as the child may have difficulty forming attachments (Choice A) is accurate. Reactive attachment disorder often leads to difficulties in forming emotional connections and caring for others due to early negative caregiving experiences.

Choice B rationale:

Assuming that the child is likely a social and outgoing individual (Choice B) contradicts the caregiver's report and does not align with the typical characteristics of reactive attachment disorder.

Choice C rationale:

Interpreting the caregiver's statement as the child experiencing normal emotional development (Choice C) is incorrect given the reported lack of caring about others or anything. This statement indicates potential attachment-related issues.

Choice D rationale:

Interpreting the caregiver's statement as the child showing affection towards others (Choice D) contradicts the reported observation of the child's lack of caring. Reactive attachment disorder is characterized by challenges in forming emotional bonds.

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Question 61 :A client diagnosed with reactive attachment disorder (RAD) has poor hygiene, growth retardation, and malnutrition. What could be the underlying reason for these physical signs?

A. Indiscriminate social behavior. B. Lack of involvement in social activities. C. Inhibited emotional withdrawal. D. Exposure to neglect or abuse.

Explanation

Choice A rationale:

Indiscriminate social behavior is not likely the underlying reason for poor hygiene, growth retardation, and malnutrition in a child with reactive attachment disorder (RAD). Indiscriminate social behavior refers to a lack of preference for familiar caregivers over unfamiliar individuals, which might result in approaching strangers, but it doesn't directly explain the physical signs mentioned in the question.

Choice B rationale:

Lack of involvement in social activities is also unlikely to be the main reason for the physical signs. While this might contribute to a child's overall well-being, RAD typically stems from early disruptions in attachment due to neglect or abuse, leading to physical and emotional consequences.

Choice C rationale:

Inhibited emotional withdrawal is a hallmark of RAD, characterized by a child's reluctance to seek or respond to comfort from caregivers. However, this choice doesn't directly explain the physical signs mentioned.

Choice D rationale:

Exposure to neglect or abuse is the most likely reason for the physical signs described. Children with RAD often experience early, severe disruptions in their attachment relationships due to neglect, maltreatment, or inconsistent care, leading to difficulties in forming healthy relationships and developmental delays including poor hygiene, growth retardation, and malnutrition.

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Question 62 :A nurse is assessing a child with reactive attachment disorder (RAD). Which of the following is a common clinical manifestation of RAD?

A. Frequent mood swings and emotional instability. B. Excessive fear of strangers and new situations. C. Rapid speech and impulsivity. D. Heightened sense of empathy and trust.

Explanation

Choice A rationale:

Frequent mood swings and emotional instability are not typical clinical manifestations of reactive attachment disorder (RAD). RAD is characterized by difficulties forming emotional bonds, not necessarily by mood swings.

Choice B rationale:

Excessive fear of strangers and new situations is a common clinical manifestation of RAD. Children with RAD often have trouble trusting and forming attachments, leading to heightened anxiety and fear in unfamiliar settings or with unfamiliar people.

Choice C rationale:

Rapid speech and impulsivity are not typically associated with RAD. These traits might be seen in other behavioral disorders but are not primary characteristics of RAD.

Choice D rationale:

Heightened sense of empathy and trust is unlikely in children with RAD. They tend to have difficulties with empathy and trust due to their attachment challenges.

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Question 63 :(Select all that apply). A nurse is providing education to parents about preventing reactive attachment disorder (RAD) in their child. What primary prevention strategies should the nurse include? Select all that apply.

A. Teaching the child about attachment and its types. B. Providing therapy to the child after signs of RAD are observed. C. Offering support groups to children who have been exposed to abuse. D. Educating caregivers about the importance of consistent bonding. E. Administering psychological tests to children to identify RAD.

Explanation

Choice A rationale:

Teaching the child about attachment and its types is a primary prevention strategy that can help children understand healthy relationships and possibly prevent attachment disorders like RAD. Educating children about attachment can promote awareness and facilitate the development of secure bonds.

Choice B rationale:

Providing therapy to the child after signs of RAD are observed is not a primary prevention strategy but rather a secondary intervention. Primary prevention aims to prevent the development of the disorder before it occurs.

Choice C rationale:

Offering support groups to children who have been exposed to abuse is a primary prevention strategy. These support groups can provide a safe space for children to share their experiences, learn healthy coping strategies, and potentially prevent the development of RAD.

Choice D rationale:

Educating caregivers about the importance of consistent bonding is a crucial primary prevention strategy. Healthy attachment bonds formed through consistent care can prevent the onset of RAD.

Choice E rationale:

Administering psychological tests to children to identify RAD is not a primary prevention strategy. Psychological tests are typically used for assessment and diagnosis, rather than prevention.

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Question 64 :A nurse is conducting a nursing assessment of a child with suspected reactive attachment disorder (RAD). The child's caregiver says, "The child never seeks comfort when upset and avoids interactions." What statement from the nurse is appropriate?

A. "It sounds like the child has a healthy attachment with you.” B. "Your child's behavior is likely a temporary phase.” C. "It's common for children to show such behaviors during development.” D. "Your description matches the characteristic of inhibited type RAD.”

Explanation

Choice A rationale:

This choice is incorrect because a child with reactive attachment disorder (RAD) is not likely to have a healthy attachment with their caregiver. RAD is characterized by difficulties in forming healthy attachments due to early neglect or inconsistent care.

Choice B rationale:

This choice is incorrect because describing the child's behavior as a "temporary phase" overlooks the severity and persistent nature of RAD symptoms. RAD is a complex and chronic condition that requires appropriate assessment and intervention.

Choice C rationale:

This choice is incorrect because while some challenging behaviors are common during child development, RAD goes beyond normal behaviors. RAD is rooted in disrupted early attachments and leads to profound difficulties in forming emotional bonds.

Choice D rationale:

This choice is correct. The nurse's response acknowledges the caregiver's concerns and accurately relates the child's behavior to the characteristics of inhibited type RAD. This response opens the door for further discussion, assessment, and potential intervention.

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Question 65 :A nurse is assessing a child with reactive attachment disorder (RAD). The child expresses feelings of sadness, guilt, and low self-esteem. Which statement is an appropriate therapeutic response from the nurse?

A. "Don't worry, these feelings will go away soon.” B. "You need to focus on positive thoughts to overcome these feelings.” C. "It's important to acknowledge your feelings and talk about them.” D. "Everyone feels this way at times, so you're not alone.”

Explanation

Choice A rationale:

This choice is incorrect because dismissing the child's feelings as temporary might invalidate their emotions and hinder therapeutic rapport. RAD-related emotions often require more comprehensive interventions.

Choice B rationale:

This choice is incorrect because telling the child to focus solely on positive thoughts oversimplifies their emotional struggles. RAD-related feelings typically require a more nuanced approach.

Choice C rationale:

This choice is correct. The nurse's response validates the child's feelings and encourages open discussion about them. This therapeutic response fosters trust, allows emotional expression, and supports the child's emotional well-being.

Choice D rationale:

This choice is incorrect because stating that everyone feels this way at times minimizes the unique challenges faced by children with RAD. Such a response might not address the underlying causes of the child's emotions.

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Question 66 :A nurse is providing education to a group of caregivers about nursing interventions for children with reactive attachment disorder (RAD). What should the nurse include as part of nursing interventions?

A. Administering medication to alleviate emotional symptoms. B. Avoiding involvement of the family in care planning. C. Reporting suspected neglect or abuse to authorities. D. Encouraging children to isolate themselves to prevent triggers.

Explanation

Choice A rationale:

This choice is incorrect because administering medication to alleviate emotional symptoms does not directly address the underlying attachment and emotional issues that children with RAD face. Medication might play a role in some cases, but it is not a core nursing intervention.

Choice B rationale:

This choice is incorrect because involving the family in care planning is essential for children with RAD. Family support and involvement are crucial components of treatment and interventions for improving attachment and relationships.

Choice C rationale:

This choice is correct. Reporting suspected neglect or abuse is an important nursing intervention for children with RAD. Early identification of potential maltreatment can lead to protective measures and appropriate interventions.

Choice D rationale:

This choice is incorrect because encouraging children to isolate themselves contradicts therapeutic goals for children with RAD. Encouraging social interaction and healthy relationships is a key aspect of treatment for this disorder.

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Disinhibited Social Engagement Disorder (DSED)

Question 67 :A nurse is assessing a child with Disinhibited Social Engagement Disorder (DSED). Which of the following is a common clinical manifestation of DSED?

A. Avoidance of all social interactions. B. Selective attachment to specific caregivers. C. Excessive familiarity with strangers. D. Emotional withdrawal from adult caregivers.

Explanation

Choice A rationale:

Avoidance of all social interactions is not a common clinical manifestation of Disinhibited Social Engagement Disorder (DSED). DSED is characterized by an extreme lack of inhibition in approaching and interacting with unfamiliar adults.

Choice B rationale:

Selective attachment to specific caregivers is not a common manifestation of DSED. This choice contradicts the nature of the disorder, which involves indiscriminate attachment behaviors towards both familiar and unfamiliar adults.

Choice C rationale:

Excessive familiarity with strangers is a common clinical manifestation of DSED. Children with DSED tend to approach and interact with strangers without the expected caution or wariness, displaying an inappropriate level of familiarity.

Choice D rationale:

Emotional withdrawal from adult caregivers is not a common manifestation of DSED. Children with DSED typically exhibit the opposite behavior, actively seeking interactions with unfamiliar adults.

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Question 68 :(Select all that apply): A nurse is collecting data during the nursing assessment of a child with Disinhibited Social Engagement Disorder (DSED). Which components should be included in the assessment? (Select three.).

A. Family history of mental health disorders. B. Recent changes in caregivers. C. Physical examination. D. Childhood experiences of comfort. E. Blood type and Rh factor.

Explanation

Choice A rationale:

Family history of mental health disorders should be included in the assessment. This information is important as there might be a genetic predisposition to mental health issues that could contribute to the development of DSED.

Choice B rationale:

Recent changes in caregivers should be assessed. Children with DSED are particularly sensitive to changes in their caregiving environment, which can exacerbate their symptoms or trigger their indiscriminate attachment behaviors.

Choice C rationale:

Physical examination is relevant in a general medical assessment, but it is not directly related to assessing Disinhibited Social Engagement Disorder (DSED) specifically.

Choice D rationale:

Childhood experiences of comfort should be assessed. These experiences can contribute to the development and manifestation of DSED, as disrupted or inconsistent caregiving early in life can influence the child's attachment behaviors.

Choice E rationale:

Blood type and Rh factor are not relevant components to assess for Disinhibited Social Engagement Disorder (DSED). This information does not have a direct impact on the diagnosis or management of the disorder.

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Question 69 :A nurse is talking to the caregiver of a child with DSED. Which statement by the caregiver indicates a need for further education?

A. "I understand that my child's behavior with strangers is a part of their condition.” B. "I think my child's attachment issues are due to their current school environment.” C. "I've noticed that my child has difficulty setting appropriate boundaries.” D. "I believe my child's excessive familiarity with adults is a normal phase.”

Explanation

Choice A rationale:

"I understand that my child's behavior with strangers is a part of their condition." This statement indicates the caregiver's understanding of the child's condition and its associated behaviors, showing appropriate awareness.

Choice B rationale:

"I think my child's attachment issues are due to their current school environment." This statement demonstrates a misconception. DSED is rooted in early developmental experiences and attachment disruptions, not current school environments.

Choice C rationale:

"I've noticed that my child has difficulty setting appropriate boundaries." This statement indicates the caregiver's recognition of a common issue associated with DSED—difficulties in establishing appropriate personal boundaries.

Choice D rationale:

"I believe my child's excessive familiarity with adults is a normal phase." This statement reflects a lack of understanding about DSED, as excessive familiarity with adults is a hallmark symptom of the disorder and is not a typical developmental phase.

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Question 70 :A nurse is assessing a child suspected of having DSED. Which statement by the child would be concerning for this disorder?

A. "I prefer spending time with my close friends.” B. "I feel comfortable approaching strangers.” C. "I only trust my parents and no one else.” D. "I get anxious in social situations.”

Explanation

Choice A rationale:

This option indicates a preference for spending time with close friends, which is within the range of normal social behavior for a child. Building friendships is an important developmental milestone.

Choice B rationale:

Feeling comfortable approaching strangers can be seen as a positive social behavior, as it suggests the child is open to new interactions. While caution is needed, it doesn't directly point to Disinhibited Social Engagement Disorder (DSED).

Choice C rationale:

The statement "I only trust my parents and no one else" is concerning for DSED. Children with this disorder often show an inability to discriminate between familiar and unfamiliar individuals, resulting in overly friendly behavior even with strangers, which contrasts with a healthy sense of wariness.

Choice D rationale:

Getting anxious in social situations might be an indicator of social anxiety, but it doesn't necessarily align with DSED, which is characterized by a lack of appropriate caution and boundaries in social interactions.

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Question 71 :A nurse is implementing nursing interventions for a child with DSED. Which intervention aims to protect the child from further harm?

A. Providing education about attachment and its types. B. Administering psychological tests for diagnosis. C. Referring the child and caregiver to a support group. D. Reporting suspected cases of neglect or abuse.

Explanation

Choice A rationale:

Educating the child and caregivers about attachment and its types is important, but it doesn't directly protect the child from further harm in the context of Disinhibited Social Engagement Disorder (DSED).

Choice B rationale:

Administering psychological tests for diagnosis is a valid step, but it's not an intervention aimed at protecting the child from harm. It's a diagnostic process, not a protective measure.

Choice C rationale:

Referring the child and caregiver to a support group can be beneficial for emotional support, but it doesn't directly address protection from harm, which is the primary concern in this scenario.

Choice D rationale:

Reporting suspected cases of neglect or abuse is crucial to ensure the child's safety. Children with DSED might engage with strangers without appropriate caution, which could expose them to potential danger. Reporting ensures that professionals can intervene to safeguard the child's well-being.

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Question 72 :A nurse is educating a group of caregivers about Disinhibited Social Engagement Disorder (DSED). What is a characteristic feature of DSED?

A. Emotionally withdrawn behavior. B. Lack of social skills. C. Selective attachment to caregivers. D. Fear of strangers.

Explanation

Choice A rationale:

Emotionally withdrawn behavior is not a characteristic feature of Disinhibited Social Engagement Disorder (DSED). DSED typically involves overly familiar behavior, not withdrawal.

Choice B rationale:

Lack of social skills could be a consequence of DSED, but it's not the primary characteristic feature. The main hallmark of DSED is an indiscriminate and overly friendly approach to both familiar and unfamiliar individuals.

Choice C rationale:

Selective attachment to caregivers is a characteristic feature of DSED. Children with this disorder may have a lack of appropriate wariness and show indiscriminate social behavior towards people they have no reason to trust, which contrasts with a typical development of forming attachments.

Choice D rationale:

Fear of strangers is not a characteristic feature of DSED. In fact, children with DSED often lack this fear and readily engage with strangers without appropriate caution.

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Question 73 :(Select all that apply): A nurse is assessing a child suspected of having Disinhibited Social Engagement Disorder (DSED). Which clinical manifestations are commonly associated with DSED? (Select three.).

A. Social withdrawal. B. Excessive familiarity with strangers. C. Emotional detachment. D. Inappropriate behavior toward caregivers. E. Poor hygiene.

Explanation

Choice A rationale:

Social withdrawal is not commonly associated with Disinhibited Social Engagement Disorder (DSED). Children with DSED tend to display excessive familiarity with strangers and inappropriate behavior towards caregivers, rather than withdrawing from social interactions.

Choice B rationale:

Excessive familiarity with strangers is a hallmark manifestation of Disinhibited Social Engagement Disorder (DSED). Children with this disorder often show a lack of appropriate fear or caution around unfamiliar individuals, readily approaching and interacting with them.

Choice C rationale:

Emotional detachment is one of the clinical manifestations commonly associated with DSED. Children with DSED may struggle with forming appropriate emotional bonds and exhibit a lack of selectivity in their social interactions, showing a lack of preference for familiar caregivers over strangers.

Choice D rationale:

Inappropriate behavior toward caregivers is another characteristic feature of Disinhibited Social Engagement Disorder (DSED). Children with DSED may not display the expected attachment-related behaviors and may engage in overly familiar or even overly intimate behaviors with individuals they barely know.

Choice E rationale:

Poor hygiene is not typically a recognized clinical manifestation of Disinhibited Social Engagement Disorder (DSED). This choice is not directly related to the core symptoms of the disorder.

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Question 74 :A nurse is talking to a caregiver of a child with DSED. The caregiver states, "My child avoids all social interactions." What does this statement suggest about the child's condition?

A. The child may have developed a secure attachment bond. B. The child is showing typical social behavior. C. The child's behavior is consistent with DSED. D. The child is emotionally withdrawn.

Explanation

Choice A rationale:

This choice is not accurate. A child avoiding social interactions is not indicative of a secure attachment bond. In fact, it suggests the opposite, as children with Disinhibited Social Engagement Disorder (DSED) tend to display overly familiar behavior with strangers and a lack of appropriate attachment to caregivers.

Choice B rationale:

The child avoiding all social interactions does not represent typical social behavior. Typically developing children seek social interactions and form connections with others, which is not the case for a child with DSED.

Choice C rationale:

The caregiver's statement that "My child avoids all social interactions" is consistent with the behavior exhibited by children with Disinhibited Social Engagement Disorder (DSED). This disorder involves a lack of appropriate social boundaries, leading to overly friendly behavior with unfamiliar individuals and minimal hesitation to engage with them.

Choice D rationale:

The term "emotionally withdrawn" does not accurately describe the behavior of a child with DSED. Children with DSED may seem socially engaging but lack the appropriate discrimination between familiar and unfamiliar individuals.

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Question 75 :A nurse is assessing a child with suspected DSED. The child says, "I like talking to new people and making friends quickly." What does this statement indicate?

A. The child has a strong attachment to caregivers. B. The child's social behavior is age-appropriate. C. The child is showing inhibited behavior. D. The child's behavior may be indicative of DSED.

Explanation

Choice A rationale:

The statement does not imply a strong attachment to caregivers. Rather, it suggests a lack of appropriate attachment-related behaviors, which is indicative of Disinhibited Social Engagement Disorder (DSED).

Choice B rationale:

The child's behavior of liking to talk to new people and make friends quickly is not considered age-appropriate. Children typically exhibit cautious behavior around strangers, unlike the behavior described, which could be a sign of DSED.

Choice C rationale:

The child's behavior does not align with inhibited behavior. Inhibited behavior would involve shyness, reluctance to engage with new people, and hesitancy in forming friendships.

Choice D rationale:

The child's statement, "I like talking to new people and making friends quickly," may be indicative of Disinhibited Social Engagement Disorder (DSED). Children with this disorder often show a lack of appropriate wariness around unfamiliar individuals and readily form relationships without discernment.

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Question 76 :

A nurse is caring for a child with DSED. Which nursing intervention is important for promoting the child's safety?

A. Encouraging emotional detachment from caregivers. B. Providing information about attachment development. C. Reporting suspected neglect or abuse cases. D. Recommending home-based therapy for the child.

Explanation

Choice A rationale:

Encouraging emotional detachment from caregivers would not be an appropriate intervention for a child with Disinhibited Social Engagement Disorder (DSED). This disorder is characterized by a lack of appropriate social boundaries and indiscriminate attachment behaviors. Encouraging emotional detachment could exacerbate the child's issues and hinder their healthy emotional development.

Choice B rationale:

Providing information about attachment development could be helpful, but it might not directly address the safety concerns of the child. DSED involves a lack of discernment in forming attachments, which can put the child at risk of engaging with potentially harmful individuals. However, promoting safety requires more immediate actions.

Choice C rationale:

(Correct Choice) Reporting suspected neglect or abuse cases is crucial for promoting the child's safety. Children with DSED are vulnerable due to their indiscriminate attachment behaviors and inability to judge potential threats accurately. If neglect or abuse is suspected, reporting to the appropriate authorities ensures that the child's safety is prioritized, interventions are initiated, and their well-being is safeguarded.

Choice D rationale:

Recommending home-based therapy for the child might be beneficial for addressing the child's disorder, but it doesn't primarily focus on their safety. While therapy can help with attachment issues, it does not directly address the potential danger the child might be exposed to if abuse or neglect is occurring.

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Exams on Abuse, Violence, Trauma, and Stressor Related Disorders

Clinical Picture of Abuse and Violence

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Child Abuse

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Elder Abuse

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Post-Traumatic Stress Disorder (PTSD)

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Acute Stress Disorder (ASD)

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Adjustment Disorder (AD)

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Table of Contents

Objectives
Introduction
Clinical Picture of Abuse and Violence
Child and Elder Abuse
Child Abuse
Elder Abuse
Trauma and Stressor Related Disorders
Post-Traumatic Stress Disorder (PTSD)
Acute Stress Disorder (ASD)
Adjustment Disorder (AD)
Reactive Attachment Disorder (RAD)
Disinhibited Social Engagement Disorder (DSED)

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Objectives

Define abuse, violence, trauma, and stressor related disorders and their types, causes, risk factors, and effects.
Identify the clinical manifestations of abuse, violence, trauma, and stressor related disorders in different populations and settings.
Describe the nursing assessment and interventions for abuse, violence, trauma, and stressor related disorders, including prevention, screening, reporting, referral, education, support, and therapy.
Apply the nursing process and evidence-based practice to provide holistic and culturally sensitive care for clients with abuse, violence, trauma, and stressor related disorders.
Evaluate the outcomes of nursing care for clients with abuse, violence, trauma, and stressor related disorders and their families.
Demonstrate ethical, legal, and professional responsibilities in caring for clients with abuse, violence, trauma, and stressor related disorders.

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Introduction

Introduction

Abuse is the intentional or unintentional infliction of physical, sexual, emotional, or financial harm or neglect on another person.
Violence is the use of physical force or power to threaten or harm oneself or others.
Trauma is the exposure to actual or threatened death, serious injury, or sexual violence.
Stressor-related disorders are a group of mental disorders that develop after exposure to a traumatic or stressful event.
Abuse, violence, trauma, and stressor-related disorders are major public health problems that affect millions of people worldwide.
Abuse, violence, trauma, and stressor-related disorders can have serious and long-lasting consequences for the physical, mental, emotional, social, and spiritual well-being of individuals, families, communities, and societies.
Nurses play a vital role in preventing, identifying, reporting, treating, and supporting clients with abuse, violence, trauma, and stressor-related disorders across the lifespan and in various settings.

Types of gender-based violence - Gender Matters

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Clinical Picture of Abuse and Violence

Abuse and violence can occur in different forms and contexts. Some of the common types of abuse and violence are:

Child abuse: any act or failure to act by a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation of a child under 18 years of age. Child abuse can be physical, sexual, emotional, or neglectful. Know symptoms of child abuse | Article | The United States Army

Elder abuse: any act or failure to act by a person in a relationship of trust that results in harm or distress to an older person. Elder abuse can be physical, sexual, emotional, financial, or neglectful.

Intimate partner violence (IPV): any physical, sexual, psychological, or economic harm or threat of harm by a current or former partner or spouse. IPV can be physical, sexual, emotional, stalking, or coercive control.

Sexual assault: any unwanted sexual contact or activity without consent or under coercion. Sexual assault can include rape, attempted rape, fondling, groping, oral sex, anal sex, penetration with objects, or exposure to pornography.

Community violence: any intentional act of interpersonal violence that occurs in public or private spaces between individuals who are not related or intimate partners. Community violence can include homicide, assault, robbery, kidnapping, terrorism, hate crimes, gang violence, school violence, workplace violence, or mass shootings.

The causes of abuse and violence are complex and multifactorial. Some of the factors that contribute to abuse and violence are:

Individual factors: such as age, gender, race/ethnicity, personality traits, mental health status, substance use disorder, history of trauma or abuse, low self-esteem, poor impulse control, anger issues, cognitive impairment, disability.
Relationship factors: such as family dynamics, marital conflict, power imbalance, poor communication skills, lack of trust or respect, isolation from social support networks.
Community factors: such as poverty, unemployment, homelessness, crime rates, lack of access to education or health care services or legal protection or social welfare programs or resources for victims/survivors.
Societal factors: such as cultural norms or values or beliefs or attitudes that condone or justify or tolerate or minimize or deny abuse or violence or discrimination or oppression based on gender or sexuality or race/ethnicity or religion or age or disability.
The effects of abuse and violence can be devastating and lasting for the victims/survivors, perpetrators, witnesses, and bystanders. Some of the effects of abuse and violence are:
- Physical effects: such as injuries, bruises, cuts, burns, fractures, internal bleeding, organ damage, sexually transmitted infections (STIs), unwanted pregnancy, chronic pain, headaches, gastrointestinal problems, cardiovascular problems, respiratory problems, immune system dysfunction.
- Psychological effects: such as post-traumatic stress disorder (PTSD), acute stress disorder (ASD), adjustment disorder (AD), depression, anxiety, panic disorder, phobias, obsessive-compulsive disorder (OCD), dissociative disorders, personality disorders, eating disorders, sleep disorders, substance use disorder, suicidal ideation or behavior.
- Emotional effects: such as fear, anger, guilt, shame, sadness, grief, loneliness, hopelessness, helplessness, low self-esteem, low self-confidence, low self-worth, distrust, resentment, bitterness.
Social effects: such as isolation, withdrawal, avoidance, detachment, alienation, rejection, stigma, discrimination, bullying, harassment, violence, abuse, exploitation, homelessness, unemployment, poverty.
Spiritual effects: such as loss of faith, meaning, purpose, values, morals, ethics, hope.

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Child and Elder Abuse

Child and elder abuse are serious forms of abuse that affect vulnerable populations who may have difficulty in protecting themselves or seeking help.
Child and elder abuse can have severe and long-term consequences for the physical, mental, emotional, social, and spiritual health and development of the victims/survivors.
Child and elder abuse can occur in various settings such as home, school, work, community, or institutional care.
Child and elder abuse can be perpetrated by various people such as parents, caregivers, relatives, friends, neighbors, teachers, co-workers, strangers, or professionals.
Child and elder abuse can be influenced by various factors such as individual characteristics of the victim/survivor or perpetrator; relationship dynamics; family structure; cultural norms; social support; economic status; legal system; and health care system.

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Child Abuse

Child abuse can be classified into four main types: physical abuse; sexual abuse; emotional abuse; neglect.
Physical abuse is the intentional use of physical force that results in or has the potential to result in physical injury to a child. Examples of physical abuse are hitting; kicking; punching; slapping; shaking; throwing; burning; biting; choking; poisoning; using weapons.
Sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend or consent to or is not developmentally prepared for or violates the laws or social taboos of society. Examples of sexual abuse are fondling; oral sex; anal sex; vaginal sex; penetration with objects; exposure to pornography; prostitution; trafficking; incest; rape.
Emotional abuse is the persistent emotional maltreatment of a child that causes severe and adverse effects on the child’s emotional development. Examples of emotional abuse are verbal insults; threats; humiliation; rejection; isolation; ignoring; blaming; manipulating; intimidating; controlling; withholding affection; denying emotional responsiveness.
Neglect is the failure to provide for a child’s basic physical or emotional or educational or medical or dental needs. Examples of neglect are inadequate food or clothing or shelter or hygiene or supervision or protection or stimulation or affection or education or health care or dental care.

Child Abuse
Child abuse can be classified into four main types: physical abuse; sexual abuse; emotional abuse; neglect.
Physical abuse is the intentional use of physical force that results in or has the potential to result in physical injury to a child. Examples of physical abuse are hitting; kicking; punching; slapping; shaking; throwing; burning; biting; choking; poisoning; using weapons.
Sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend or consent to or is not developmentally prepared for or violates the laws or social taboos of society. Examples of sexual abuse are fondling; oral sex; anal sex; vaginal sex; penetration with objects; exposure to pornography; prostitution; trafficking; incest; rape.
Emotional abuse is the persistent emotional maltreatment of a child that causes severe and adverse effects on the child’s emotional development. Examples of emotional abuse are verbal insults; threats; humiliation; rejection; isolation; ignoring; blaming; manipulating; intimidating; controlling; withholding affection; denying emotional responsiveness.
Neglect is the failure to provide for a child’s basic physical or emotional or educational or medical or dental needs. Examples of neglect are inadequate food or clothing or shelter or hygiene or supervision or protection or stimulation or affection or education or health care or dental care.
Clinical Manifestations of Child Abuse
The clinical manifestations of child abuse may vary depending on the type and severity and duration and frequency of the abuse and the age and developmental stage and personality and coping skills of the child.
Behavioral signs: such as fear or anxiety or depression or aggression or withdrawal or low self-esteem or poor social skills or difficulty trusting others or difficulty forming attachments or difficulty expressing emotions or difficulty coping with stress or difficulty concentrating or learning or memory problems or nightmares or sleep problems or eating problems or substance use problems or self-harm or suicidal thoughts or behaviors.
Sexual signs: such as sexualized behavior or language or knowledge that is inappropriate for the child’s age or developmental level. The child may also show signs of genital or anal trauma or irritation or infection or pain or bleeding or discharge or pregnancy or STIs.
Nursing Assessment of Child Abuse
The nursing assessment of child abuse involves collecting subjective and objective data from the child and the caregiver and other sources such as family members, teachers, social workers, or health care providers.
The nursing assessment of child abuse should be done in a safe, private, and comfortable environment with the child’s consent and cooperation. The nurse should use a calm, gentle, and supportive approach and avoid leading, suggestive, or judgmental questions. The nurse should also use developmentally appropriate language and tools such as dolls, drawings, or games to facilitate communication with the child.
The nursing assessment of child abuse should include the following components:
- History: The nurse should obtain a comprehensive history of the child’s physical, mental, emotional, social, and spiritual health and development; family structure and dynamics; cultural background and beliefs; exposure to abuse or violence; current situation and concerns; coping strategies and support systems; strengths and resources.
- Physical examination: The nurse should perform a thorough physical examination of the child’s head, neck, chest, abdomen, back, extremities, genitals, anus, and skin. The nurse should document any signs of injury or trauma such as location, size, shape, color, pattern, stage of healing, and consistency with the history given by the child or caregiver. The nurse should also assess the child’s vital signs, growth parameters, nutritional status, developmental milestones, and immunization status.
- Laboratory tests: The nurse should order laboratory tests as indicated by the history and physical examination. Some of the common laboratory tests for child abuse are complete blood count (CBC), coagulation studies, electrolytes, liver function tests (LFTs), renal function tests (RFTs), urine analysis (UA), urine toxicology screen (UTS), blood alcohol level (BAL), blood cultures, wound cultures, STI tests, pregnancy tests.
- Diagnostic tests: The nurse should order diagnostic tests as indicated by the history and physical examination. Some of the common diagnostic tests for child abuse are x-rays, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, ultrasound, electroencephalogram (EEG), electrocardiogram (EKG), echocardiogram, bone scan, skeletal survey.
Nursing Interventions for Child Abuse
The nursing interventions for child abuse are based on the nursing process and evidence-based practice. The nursing interventions for child abuse aim to prevent further harm; protect the child’s rights; promote the child’s safety; report the suspected or confirmed abuse; refer the child and the caregiver to appropriate services; educate the child and the caregiver about abuse prevention and treatment; support the child’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for child abuse are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of child abuse. Primary prevention strategies include providing education, information, and resources to parents, caregivers, children, and communities about child development, parenting skills, stress management, conflict resolution, anger management, substance use prevention, and abuse prevention. Secondary prevention strategies include screening children and caregivers for risk factors or signs of abuse; providing counseling, therapy, support groups, home visits, crisis intervention, and respite care to families at risk of abuse; and monitoring children and caregivers for changes in behavior or health status. Tertiary prevention strategies include reporting suspected or confirmed abuse to the appropriate authorities; providing medical care, legal assistance, social services, shelter, protection orders, and advocacy to children and caregivers who have experienced abuse; and facilitating reunification or alternative placement for children who have been removed from their homes due to abuse.
- Protection: The nurse should protect the child’s rights according to the United Nations Convention on the Rights of the Child. The nurse should respect the child’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the child from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment, supplies, and medications to prevent or treat complications or infections. The nurse should also protect the child from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the child.
- Reporting: The nurse should report any suspected or confirmed cases of child abuse to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the abuse in a clear, concise, and objective manner. The nurse should also inform the child and the caregiver about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the child and the caregiver to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as pediatrician, surgeon, dentist, ophthalmologist, otolaryngologist, dermatologist, gynecologist, urologist, endocrinologist, neurologist, psychiatrist, psychologist, nurse practitioner, physician assistant, nurse, social worker, pharmacist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, child advocate, guardian ad litem, court-appointed special advocate (CASA).
  - Social services: such as child protective services (CPS), foster care, adoption, kinship care, group home, residential treatment center, shelter, transitional housing, independent living program.
  - Educational services: such as teacher, counselor, tutor, special education teacher, speech therapist, occupational therapist, physical therapist, school nurse, school social worker.
  - Community services: such as child abuse prevention program, family resource center, crisis hotline, helpline, support group, peer mentor, mentor, volunteer, faith-based organization.
- Education: The nurse should educate the child and the caregiver about abuse prevention and treatment. The nurse should provide accurate, relevant, and understandable information about the causes, types, effects, and signs of abuse; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the child and the caregiver; and the importance of follow-up and adherence to care.
- Support: The nurse should support the child’s physical, mental, emotional, social, and spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs and preferences and goals of the child. The nurse should also provide therapeutic communication and active listening and empathy and validation and encouragement and praise to the child. The nurse should also facilitate the development of a trusting and respectful and collaborative relationship with the child. The nurse should also promote the empowerment and resilience and recovery of the child. The nurse should also involve the family or significant others or community members in the care of the child as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the child and the caregiver. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
  - The child is free from further harm or injury.
  - The child reports or demonstrates reduced pain or discomfort.
  - The child’s physical wounds or infections are healed or treated.
  - The child’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
  - The child’s growth parameters or developmental milestones are appropriate for age or show improvement.
  - The child reports or demonstrates reduced fear or anxiety or depression or aggression or withdrawal or low self-esteem or poor social skills or difficulty trusting others or difficulty forming attachments or difficulty expressing emotions or difficulty coping with stress or difficulty concentrating or learning or memory problems or nightmares or sleep problems or eating problems or substance use problems or self-harm or suicidal thoughts or behaviors.
  - The child reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or attachment to others or expression of emotions or coping with stress or concentration or learning or memory skills.
  - The child reports having a positive outlook on life and a sense of meaning and purpose.
  - The child reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
  - The child reports having a safe and secure environment at home, school, work, community or institutional care. The child reports having a safety plan and protection measures in place.
    - - The child reports or demonstrates reduced involvement or exposure to abuse or violence or trauma or stressors.
    - - The child reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
    - - The child reports or demonstrates increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments.
    - - The child reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.
    - - The caregiver reports or demonstrates reduced risk factors or signs of abuse; increased protective factors or signs of support; increased knowledge and skills about child development, parenting, stress management, conflict resolution, anger management, substance use prevention, and abuse prevention; increased awareness and acceptance of the child’s needs and feelings; increased communication and cooperation with the child and other professionals; increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments; increased satisfaction with the quality of care and the relationship with the nurse and other professionals.
The nurse should also monitor for any complications or adverse effects of the abuse or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the child and the caregiver. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.
Some of the common clinical manifestations of child abuse are:
- Physical signs: such as injuries or bruises or burns or fractures or scars or bites or infections or bleeding or pain or swelling or marks from objects or cords or belts. The injuries may be in various stages of healing or inconsistent with the history given by the child or caregiver or located in unusual places such as genitals or buttocks or back or face. The child may also show signs of malnutrition or dehydration or poor growth or developmental delay or failure to thrive.

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Elder Abuse

Elder abuse is any act or failure to act by a person in a relationship of trust that results in harm or distress to an older person. Elder abuse can be physical, sexual, emotional, financial, or neglectful.

Physical abuse is the intentional use of physical force that results in or has the potential to result in physical injury to an older person. Examples of physical abuse are hitting; kicking; punching; slapping; shaking; pushing; pulling; dragging; burning; biting; choking; poisoning; using weapons.
Sexual abuse is any unwanted sexual contact or activity without consent or under coercion. Examples of sexual abuse are fondling; oral sex; anal sex; vaginal sex; penetration with objects; exposure to pornography; prostitution; trafficking.
Emotional abuse is the intentional infliction of mental pain or anguish or distress on an older person. Examples of emotional abuse are verbal insults; threats; humiliation; intimidation; isolation; ignoring; blaming; manipulating; controlling; withholding affection; denying emotional responsiveness.
Financial abuse is the illegal or improper or unauthorized use or exploitation or mismanagement of an older person’s money or property or assets or benefits. Examples of financial abuse are stealing; forging; coercing; deceiving; undue influencing; withholding; misappropriating; overcharging; fraud; scam.
Neglect is the failure to provide for an older person’s basic physical or emotional or social or medical needs. Examples of neglect are inadequate food or clothing or shelter or hygiene or supervision or protection or stimulation or affection or health care.

Clinical Manifestations of Elder Abuse

The clinical manifestations of elder abuse may vary depending on the type and severity and duration and frequency of the abuse and the age and health status and cognitive function and personality and coping skills of the older person.
Some of the common clinical manifestations of elder abuse are:
- Physical signs: such as injuries or bruises or burns or fractures or scars or bites or infections or bleeding or pain or swelling or marks from objects or cords or belts. The injuries may be in various stages of healing or inconsistent with the history given by the older person or caregiver or located in unusual places such as genitals or buttocks or back or face. The older person may also show signs of malnutrition or dehydration or poor hygiene or pressure ulcers or contractures or infections.

Behavioral signs: such as fear or anxiety or depression or aggression or withdrawal or confusion or dementia or delirium or hallucinations or paranoia or low self-esteem or poor social skills or difficulty trusting others or difficulty expressing emotions or difficulty coping with stress or difficulty concentrating or memory problems or sleep problems or eating problems or substance use problems or self-harm or suicidal thoughts or behaviors.
Sexual signs: such as sexualized behavior or language that is inappropriate for the older person’s age or cognitive level. The older person may also show signs of genital or anal trauma or irritation or infection or pain or bleeding or discharge or STIs.
Financial signs: such as unexplained changes in the older person’s financial situation or status such as missing money or property or assets or benefits; unpaid bills or debts or taxes; forged checks or signatures; unauthorized transactions or withdrawals; unusual purchases or donations; exploitation by family members, caregivers, friends, neighbors, strangers, professionals, or organizations.
Neglect signs: such as inadequate food or clothing or shelter or hygiene or supervision or protection or stimulation or affection; lack of access to health care services or medications or assistive devices; lack of participation in social activities or hobbies or interests; lack of respect or dignity; lack of autonomy or choice.

Nursing Interventions for Elder Abuse

The nursing interventions for elder abuse are based on the nursing process and evidence-based practice. The nursing interventions for elder abuse aim to prevent further harm; protect the older person’s rights; promote the older person’s safety; report the suspected or confirmed abuse; refer the older person and the caregiver to appropriate services; educate the older person and the caregiver about abuse prevention and treatment; support the older person’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for elder abuse are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of elder abuse. Primary prevention strategies include providing education, information, and resources to older persons, caregivers, families, and communities about aging, health care needs, legal rights, financial management, and abuse prevention. Secondary prevention strategies include screening older persons and caregivers for risk factors or signs of abuse; providing counseling, therapy, support groups, home visits, crisis intervention, and respite care to older persons and caregivers at risk of abuse; and monitoring older persons and caregivers for changes in behavior or health status. Tertiary prevention strategies include reporting suspected or confirmed abuse to the appropriate authorities; providing medical care or legal assistance or social services or shelter or protection orders or advocacy to older persons who have experienced abuse; and facilitating reunification or alternative placement for older persons who have been removed from their homes due to abuse.
- Protection: The nurse should protect the older person’s rights according to the United Nations Principles for Older Persons. The nurse should respect the older person’s dignity or independence or participation or care or self-fulfillment. The nurse should also protect the older person from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment or supplies or medications to prevent or treat complications or infections. The nurse should also protect the older person from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the older person.
- Reporting: The nurse should report any suspected or confirmed cases of elder abuse to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the abuse in a clear, concise, and objective manner. The nurse should also inform the older person and the caregiver about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the older person and the caregiver to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as geriatrician, surgeon, dentist, ophthalmologist, otolaryngologist, dermatologist, gynecologist, urologist, endocrinologist, neurologist, psychiatrist, psychologist, nurse practitioner, physician assistant, nurse, social worker, pharmacist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, elder advocate, guardian ad litem, court-appointed special advocate (CASA).
  - Social services: such as adult protective services (APS), foster care, adoption, kinship care, group home, residential treatment center, shelter, transitional housing, independent living program.
  - Educational services: such as teacher, counselor, tutor, special education teacher, speech therapist, occupational therapist, physical therapist, school nurse, school social worker.
  - Community services: such as elder abuse prevention program, senior center, crisis hotline, helpline, support group, peer mentor, mentor, volunteer, faith-based organization.
- Education: The nurse should educate the older person and the caregiver about abuse prevention and treatment. The nurse should provide accurate or relevant or understandable information about the causes or types or effects or signs of abuse; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the older person and the caregiver; and the importance of follow-up and adherence to care.

Support: The nurse should support the older person’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs or preferences or goals of the older person. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the older person. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the older person. The nurse should also promote the empowerment or resilience or

Nursing Interventions for Elder Abuse

The nursing interventions for elder abuse are based on the nursing process and evidence-based practice. The nursing interventions for elder abuse aim to prevent further harm; protect the older person’s rights; promote the older person’s safety; report the suspected or confirmed abuse; refer the older person and the caregiver to appropriate services; educate the older person and the caregiver about abuse prevention and treatment; support the older person’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for elder abuse are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of elder abuse. Primary prevention strategies include providing education, information, and resources to older persons, caregivers, families, and communities about aging, health care needs, legal rights, financial management, and abuse prevention. Secondary prevention strategies include screening older persons and caregivers for risk factors or signs of abuse; providing counseling, therapy, support groups, home visits, crisis intervention, and respite care to older persons and caregivers at risk of abuse; and monitoring older persons and caregivers for changes in behavior or health status. Tertiary prevention strategies include reporting suspected or confirmed abuse to the appropriate authorities; providing medical care or legal assistance or social services or shelter or protection orders or advocacy to older persons who have experienced abuse; and facilitating reunification or alternative placement for older persons who have been removed from their homes due to abuse.
- Protection: The nurse should protect the older person’s rights according to the United Nations Principles for Older Persons. The nurse should respect the older person’s dignity or independence or participation or care or self-fulfillment. The nurse should also protect the older person from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment or supplies or medications to prevent or treat complications or infections. The nurse should also protect the older person from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the older person.
- Reporting: The nurse should report any suspected or confirmed cases of elder abuse to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the abuse in a clear, concise, and objective manner. The nurse should also inform the older person and the caregiver about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the older person and the caregiver to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as geriatrician, surgeon, dentist, ophthalmologist, otolaryngologist, dermatologist, gynecologist, urologist, endocrinologist, neurologist, psychiatrist, psychologist, nurse practitioner, physician assistant, nurse, social worker, pharmacist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, elder advocate, guardian ad litem, court-appointed special advocate (CASA).
  - Social services: such as adult protective services (APS), foster care, adoption, kinship care, group home, residential treatment center, shelter, transitional housing, independent living program.
  - Educational services: such as teacher, counselor, tutor, special education teacher, speech therapist, occupational therapist, physical therapist, school nurse, school social worker.
  - Community services: such as elder abuse prevention program, senior center, crisis hotline, helpline, support group, peer mentor, mentor, volunteer, faith-based organization.
- Education: The nurse should educate the older person and the caregiver about abuse prevention and treatment. The nurse should provide accurate or relevant or understandable information about the causes or types or effects or signs of abuse; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the older person and the caregiver; and the importance of follow-up and adherence to care.
- Support: The nurse should support the older person’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs or preferences or goals of the older person. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the older person. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the older person. The nurse should also promote the empowerment or resilience or recovery of the older person. The nurse should also involve the family or significant others or community members in the care of the older person as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the older person and the caregiver. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
  - The older person is free from further harm or injury.
  - The older person reports or demonstrates reduced pain or discomfort.
  - The older person’s physical wounds or infections are healed or treated.
  - The older person’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
  - The older person’s functional status or nutritional status or cognitive function or mental status or mood or affect or behavior or pain level are appropriate for age or show improvement.
  - The older person reports or demonstrates reduced fear or anxiety or depression or aggression or withdrawal or confusion or dementia or delirium or hallucinations or paranoia or low self-esteem or poor social skills or difficulty trusting others or difficulty expressing emotions or difficulty coping with stress or difficulty concentrating or memory problems or sleep problems or eating problems or substance use problems or self-harm or suicidal thoughts or behaviors.
  - The older person reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress or concentration or memory skills.
  - The older person reports having a positive outlook on life and a sense of meaning and purpose.
  - The older person reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
  - The older person reports having a safe and secure environment at home, work, community, or institutional care. The older person reports having a safety plan and protection measures in place.
  - The older person reports or demonstrates reduced involvement or exposure to abuse or violence or trauma or stressors.
  - The older person reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
    - - The older person reports or demonstrates increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments.
    - - The older person reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.
    - - The caregiver reports or demonstrates reduced risk factors or signs of abuse; increased protective factors or signs of support; increased knowledge and skills about aging, health care needs, legal rights, financial management, and abuse prevention; increased awareness and acceptance of the older person’s needs and feelings; increased communication and cooperation with the older person and other professionals; increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments; increased satisfaction with the quality of care and the relationship with the nurse and other professionals.

The nurse should also monitor for any complications or adverse effects of the abuse or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the older person and the caregiver. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Elder Abuse

Trauma and Stressor Related Disorders

Trauma and stressor-related disorders are a group of mental disorders that develop after exposure to a traumatic or stressful event. Trauma and stressor-related disorders include post-traumatic stress disorder (PTSD), acute stress disorder (ASD), adjustment disorder (AD), reactive attachment disorder (RAD), disinhibited social engagement disorder (DSED), and other specified trauma and stressor-related disorder (OSTSD).
A traumatic event is an event that involves actual or threatened death, serious injury, or sexual violence to oneself or others. Examples of traumatic events are natural disasters, war, terrorism, violence, abuse, rape, accidents, illnesses, injuries, and losses.
A stressful event is an event that involves a significant change or disruption in one’s life that causes distress or difficulty in coping. Examples of stressful events are divorce, separation, marriage, birth, death, moving, school, work, retirement, financial problems, and legal problems. Trauma and stressor-related disorders can affect anyone regardless of age, gender, race/ethnicity, culture, or background. Trauma and stressor-related disorders can have serious and long-lasting consequences for the physical, mental, emotional, social, and spiritual well-being of individuals, families, communities, and societies.

Clinical Manifestations of PTSD

The clinical manifestations of PTSD may vary depending on the type and severity and duration and frequency of the traumatic event; the age and developmental stage and personality and coping skills of the individual; the availability of social support; the presence of comorbid conditions.

Some of the common clinical manifestations of PTSD are:
- Physical signs: such as headaches; gastrointestinal problems; cardiovascular problems; respiratory problems; immune system dysfunction; chronic pain; fatigue; substance use disorder; suicidal ideation or behavior.
- Psychological signs: such as depression; anxiety; panic disorder; phobias; obsessive-compulsive disorder (OCD); dissociative disorders; personality disorders; eating disorders; and sleep disorders.
- Emotional signs: such as fear; anger; guilt; shame; sadness; grief; loneliness; hopelessness; helplessness; low self-esteem; low self-confidence; low self-worth; distrust; resentment; and bitterness.
- Social signs: such as isolation or withdrawal or avoidance detachment alienation or rejection or stigma discrimination or bullying harassment or violence or abuse or exploitation.
- Spiritual signs: such as loss of faith or meaning or purpose or values or morals or ethics or hope.

Nursing Interventions for PTSD

The nursing interventions for PTSD are based on the nursing process and evidence-based practice. The nursing interventions for PTSD aim to prevent further harm; protect the individual’s rights; promote the individual’s safety; report the suspected or confirmed trauma; refer the individual to appropriate services; educate the individual about trauma prevention and treatment; support the individual’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for PTSD are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of PTSD. Primary prevention strategies include providing education, information, and resources to individuals, families, and communities about trauma, its causes, types, effects, and signs; the available services and resources; and coping strategies and self-care techniques. Secondary prevention strategies include screening individuals for risk factors or signs of PTSD; providing counseling, therapy, support groups, crisis intervention, and debriefing to individuals who have been exposed to trauma or are at risk of developing PTSD; and monitoring individuals for changes in behavior or health status. Tertiary prevention strategies include providing medical care, legal assistance, social services, shelter, protection orders, and advocacy to individuals who have developed PTSD; and facilitating recovery or rehabilitation or reintegration for individuals who have been affected by trauma.
- Protection: The nurse should protect the individual’s rights according to the United Nations Declaration of Human Rights. The nurse should respect the individual’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the individual from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment, supplies, and medications to prevent or treat complications or infections. The nurse should also protect the individual from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the individual.
- Reporting: The nurse should report any suspected or confirmed cases of trauma to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the trauma in a clear, concise, and objective manner. The nurse should also inform the individual about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the individual to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as physician, surgeon, nurse practitioner, physician assistant, nurse, social worker, pharmacist, psychiatrist, and psychologist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, victim advocate, guardian ad litem, and court-appointed special advocate (CASA).
  - Social services: such as social worker, case manager, counselor, therapist, support group facilitator, crisis intervention worker, debriefing worker.
  - Community services: such as trauma prevention programs, crisis hotlines, helplines, support groups, peer mentors, mentors, volunteers, and faith-based organizations.
- Education: The nurse should educate the individual about trauma prevention and treatment. The nurse should provide accurate or relevant or understandable information about trauma or its causes or types or effects or signs; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the individual; and the importance of follow-up and adherence to care.
- Support: The nurse should support the individual’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs or preferences or goals of the individual. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the individual. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the individual. The nurse should also promote the empowerment or resilience or recovery of the individual. The nurse should also involve the family or significant others or community members in the care of the individual as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the individual. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
  - The individual is free from further harm or injury.
  - The individual reports or demonstrates reduced pain or discomfort.
  - The individual’s physical wounds or infections are healed or treated.
  - The individual’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
  - The individual reports or demonstrates reduced intrusion symptoms or avoidance symptoms or negative alterations in cognition and mood or alterations in arousal and reactivity.
  - The individual reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress or concentration or memory skills.
  - The individual reports having a positive outlook on life and a sense of meaning and purpose.
  - The individual reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
  - The individual reports having a safe and secure environment at home, work, community, or institutional care. The individual reports having a safety plan and protection measures in place.
  - The individual reports or demonstrates reduced involvement or exposure to trauma or stressors.
  - The individual reports or demonstrates increased involvement or participation in positive activities or hobbies interests or goals.
  - The individual reports or demonstrates increased adherence to medical care, legal assistance, social services, community services, and follow-up appointments.
  - The individual reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.
The nurse should also monitor for any complications or adverse effects of the trauma or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, and dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the individual. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Trauma and Stressor Related Disorders

Post-Traumatic Stress Disorder (PTSD)

Post Traumatic Stress Disorder Ptsd Signs And Symptoms Stock ...

Post-traumatic stress disorder (PTSD) is a mental disorder that develops after exposure to a traumatic event that causes intense fear or horror or helplessness.
PTSD is characterized by four main symptom clusters: intrusion symptoms; avoidance symptoms; negative alterations in cognition and mood; and alterations in arousal and reactivity.
Intrusion symptoms are recurrent and involuntary and intrusive memories or dreams flashbacks or distressing thoughts or feelings related to the traumatic event.
Avoidance symptoms are persistent and deliberate efforts to avoid or escape from reminders of the traumatic event such as people or places objects activities situations thoughts or feelings.
Negative alterations in cognition and mood are persistent and pervasive changes in the way one thinks or feels about oneself others or the world after the traumatic event such as negative beliefs or expectations of self-blame guilt shame anger or fear; diminished interest or participation in activities; detachment or estrangement from others; inability to experience positive emotions.
Alterations in arousal and reactivity are persistent and excessive increases in one’s level of alertness or responsiveness after the traumatic event such as irritability or aggression; recklessness or impulsivity; hypervigilance; exaggerated startle response; difficulty concentrating; and difficulty sleeping.

Take Practice Test on Post-Traumatic Stress Disorder (PTSD)

Acute Stress Disorder (ASD)

Acute Stress Disorder - The Wellness Corner

Acute stress disorder (ASD) is a mental disorder that develops after exposure to a traumatic event that causes intense fear or horror or helplessness.
ASD is characterized by nine or more symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, occurring within one month of the traumatic event and lasting for at least three days and up to one month.
Intrusion symptoms are recurrent and involuntary and intrusive memories or dreams or flashbacks or distressing thoughts or feelings related to the traumatic event.
Negative mood symptoms are persistent and pervasive inability to experience positive emotions such as happiness, satisfaction, or love after the traumatic event.
Dissociation symptoms are altered sense of reality or detachment from oneself or one’s surroundings or inability to remember important aspects of the traumatic event.
Avoidance symptoms are persistent and deliberate efforts to avoid or escape from reminders of the traumatic event such as people, places, objects, activities, situations, thoughts, or feelings.
Arousal symptoms are persistent and excessive increases in one’s level of alertness or responsiveness after the traumatic event such as irritability or aggression; recklessness or impulsivity; hypervigilance; exaggerated startle response; difficulty concentrating; difficulty sleeping.

Clinical Manifestations of ASD

The clinical manifestations of ASD may vary depending on the type and severity and duration and frequency of the traumatic event; the age and developmental stage and personality and coping skills of the individual; the availability of social support; the presence of comorbid conditions.
Some of the common clinical manifestations of ASD are:
- Physical signs: such as headaches; gastrointestinal problems; cardiovascular problems; respiratory problems; immune system dysfunction; chronic pain; fatigue; substance use disorder; suicidal ideation or behavior.
- Psychological signs: such as depression; anxiety; panic disorder; phobias; obsessive-compulsive disorder (OCD); dissociative disorders; personality disorders; eating disorders; sleep disorders.
- Emotional signs: such as fear; anger; guilt; shame; sadness; grief; loneliness; hopelessness; helplessness; low self-esteem; low self-confidence; low self-worth; distrust; resentment; bitterness.
- Social signs: such as isolation or withdrawal or avoidance or detachment or alienation or rejection or stigma or discrimination or bullying or harassment or violence or abuse or exploitation.
- Spiritual signs: such as loss of faith or meaning or purpose or values or morals or ethics or hope.

Nursing Assessment of ASD

The nursing assessment of ASD involves collecting subjective and objective data from the individual and other sources such as family members, friends, peers, professionals, or records.
The nursing assessment of ASD should be done in a safe, private, and comfortable environment with the individual’s consent and cooperation. The nurse should use a calm, gentle, and supportive approach and avoid leading, suggestive, or judgmental questions. The nurse should also use developmentally appropriate language and tools such as pictures, charts, or scales to facilitate communication with the individual.
The nursing assessment of ASD should include the following components:
- History: The nurse should obtain a comprehensive history of the individual’s physical, mental, emotional, social, and spiritual health and well-being; exposure to traumatic events; current situation and concerns; coping strategies and support systems; strengths and resources.
- Physical examination: The nurse should perform a thorough physical examination of the individual’s head, neck, chest, abdomen, back, extremities, genitals, anus, and skin. The nurse should document any signs of injury or trauma or infection or pain or discomfort. The nurse should also assess the individual’s vital signs, nutritional status, pain level, and substance use status.
- Laboratory tests: The nurse should order laboratory tests as indicated by the history and physical examination. Some of the common laboratory tests for ASD are complete blood count (CBC), coagulation studies, electrolytes, liver function tests (LFTs), renal function tests (RFTs), urine analysis (UA), urine toxicology screen (UTS), blood alcohol level (BAL), blood cultures, wound cultures, STI tests.
- Diagnostic tests: The nurse should order diagnostic tests as indicated by the history and physical examination. Some of the common diagnostic tests for ASD are x-rays, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, ultrasound, electroencephalogram (EEG), electrocardiogram (EKG), echocardiogram.
- Psychological tests: The nurse should administer psychological tests as indicated by the history and physical examination. Some of the common psychological tests for ASD are Acute Stress Disorder Scale (ASDS), Acute Stress Disorder Interview (ASDI), Structured Clinical Interview for DSM-5 Disorders (SCID-5), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Impact of Event Scale-Revised (IES-R), Dissociative Experiences Scale (DES), Personality Assessment Inventory (PAI).

Nursing Interventions for ASD

The nursing interventions for ASD are based on the nursing process and evidence-based practice. The nursing interventions for ASD aim to prevent further harm; protect the individual’s rights; promote the individual’s safety; report the suspected or confirmed trauma; refer the individual to appropriate services; educate the individual about trauma prevention and treatment; support the individual’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for ASD are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of ASD. Primary prevention strategies include providing education, information, and resources to individuals, families, and communities about trauma, its causes, types, effects, and signs; the available services and resources; and the coping strategies and self-care techniques. Secondary prevention strategies include screening individuals for risk factors or signs of ASD; providing counseling, therapy, support groups, crisis intervention, and debriefing to individuals who have been exposed to trauma or are at risk of developing ASD; and monitoring individuals for changes in behavior or health status. Tertiary prevention strategies include providing medical care, legal assistance, social services, shelter, protection orders, and advocacy to individuals who have developed ASD; and facilitating recovery or rehabilitation or reintegration for individuals who have been affected by trauma.
- Protection: The nurse should protect the individual’s rights according to the United Nations Declaration of Human Rights. The nurse should respect the individual’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the individual from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment, supplies, and medications to prevent or treat complications or infections. The nurse should also protect the individual from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the individual.
- Reporting: The nurse should report any suspected or confirmed cases of trauma to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the trauma in a clear, concise, and objective manner. The nurse should also inform the individual about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the individual to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as physician, surgeon, nurse practitioner, physician assistant, nurse, social worker, pharmacist, psychiatrist, psychologist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, victim advocate, guardian ad litem, court-appointed special advocate (CASA).
  - Social services: such as social worker, case manager, counselor, therapist, support group facilitator, crisis intervention worker, debriefing worker.
  - Community services: such as trauma prevention program or crisis hotline or helpline or support group or peer mentor or mentor or volunteer or faith-based organization.
- Education: The nurse should educate the individual about trauma prevention and treatment. The nurse should provide accurate or relevant or understandable information about trauma or its causes or types or effects or signs; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the individual; and the importance of follow-up and adherence to care.
- Support: The nurse should support the individual’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs or preferences or goals of the individual. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the individual. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the individual. The nurse should also promote the empowerment or resilience or recovery of the individual. The nurse should also involve the family or significant others or community members in the care of the individual as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the individual. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:

The individual is free from further harm or injury.
The individual reports or demonstrates reduced pain or discomfort.
The individual’s physical wounds or infections are healed or treated.
The individual’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
The individual reports or demonstrates reduced intrusion symptoms or avoidance symptoms or negative mood symptoms or dissociation symptoms or arousal symptoms.
The individual reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress or concentration or memory skills.
The individual reports having a positive outlook on life and a sense of meaning and purpose.
The individual reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
The individual reports having a safe and secure environment at home, work, community, or institutional care. The individual reports having a safety plan and protection measures in place.
The individual reports or demonstrates reduced involvement or exposure to trauma or stressors.
The individual reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
The individual reports or demonstrates increased adherence to medical care, legal assistance, social services, community services, and follow-up appointments.
The individual reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.

The nurse should also monitor for any complications or adverse effects of the trauma or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the individual. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Acute Stress Disorder (ASD)

Adjustment Disorder (AD)

What in the world is an Adjustment Disorder?

Adjustment disorder (AD) is a mental disorder that develops after exposure to a stressful event that causes significant distress or difficulty in coping. AD is characterized by emotional or behavioral symptoms that are out of proportion to the severity or intensity of the stressor or that impair one’s functioning or relationships.
AD can be classified into six subtypes based on the predominant symptom: depressed mood; anxiety; mixed anxiety and depressed mood; disturbance of conduct; mixed disturbance of emotions and conduct; unspecified.
A stressful event is an event that involves a significant change or disruption in one’s life that causes distress or difficulty in coping. Examples of stressful events are divorce, separation, marriage, birth, death, moving, school, work, retirement, financial problems, legal problems.

Clinical Manifestations of AD

The clinical manifestations of AD may vary depending on the type and severity and duration and frequency of the stressful event; the age and developmental stage and personality and coping skills of the individual; the availability of social support; the presence of comorbid conditions.
Some of the common clinical manifestations of AD are:
- Physical signs: such as headaches; gastrointestinal problems; cardiovascular problems; respiratory problems; immune system dysfunction; chronic pain; fatigue; substance use disorder; suicidal ideation or behavior.
- Psychological signs: such as depression; anxiety; panic disorder; phobias; obsessive-compulsive disorder (OCD); eating disorders; sleep disorders.
- Emotional signs: such as sadness; grief; loneliness; hopelessness; helplessness; anger; guilt; shame; fear; anxiety; low self-esteem; low self-confidence; low self-worth; distrust; resentment; bitterness.
- Behavioral signs: such as withdrawal or isolation or avoidance or detachment or alienation or rejection; aggression or violence or vandalism or theft or lying or cheating or truancy or running away; recklessness or impulsivity or risk-taking; poor performance or attendance or participation in school or work; poor hygiene or grooming; changes in appetite or weight; changes in sleep patterns; substance use disorder; self-harm; suicidal thoughts or behaviors.

Nursing Assessment of AD

The nursing assessment of AD involves collecting subjective and objective data from the individual and other sources such as family members, friends, peers, professionals, or records.
The nursing assessment of AD should be done in a safe, private, and comfortable environment with the individual’s consent and cooperation. The nurse should use a calm, gentle, and supportive approach and avoid leading, suggestive, or judgmental questions. The nurse should also use developmentally appropriate language and tools such as pictures, charts, or scales to facilitate communication with the individual.
The nursing assessment of AD should include the following components:
- History: The nurse should obtain a comprehensive history of the individual’s physical, mental, emotional, social, and spiritual health and well-being; exposure to stressful events; current situation and concerns; coping strategies and support systems; strengths and resources.
- Physical examination: The nurse should perform a thorough physical examination of the individual’s head, neck, chest, abdomen, back, extremities, genitals, anus, and skin. The nurse should document any signs of injury or infection or pain or discomfort. The nurse should also assess the individual’s vital signs, nutritional status, pain level, and substance use status.
- Laboratory tests: The nurse should order laboratory tests as indicated by the history and physical examination. Some of the common laboratory tests for AD are complete blood count (CBC), coagulation studies, electrolytes, liver function tests (LFTs), renal function tests (RFTs), urine analysis (UA), urine toxicology screen (UTS), blood alcohol level (BAL), blood cultures, wound cultures.
- Diagnostic tests: The nurse should order diagnostic tests as indicated by the history and physical examination. Some of the common diagnostic tests for AD are x-rays, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, ultrasound, electroencephalogram (EEG), electrocardiogram (EKG), echocardiogram.
- Psychological tests: The nurse should administer psychological tests as indicated by the history and physical examination. Some of the common psychological tests for AD are Structured Clinical Interview for DSM-5 Disorders (SCID-5), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Eating Disorder Inventory-3 (EDI-3), Pittsburgh Sleep Quality Index (PSQI).

Nursing Interventions for AD

The nursing interventions for AD are based on the nursing process and evidence-based practice. The nursing interventions for AD aim to prevent further harm; protect the individual’s rights; promote the individual’s safety; report the suspected or confirmed stressor; refer the individual to appropriate services; educate the individual about stress prevention and treatment; support the individual’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for AD are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of AD. Primary prevention strategies include providing education, information, and resources to individuals, families, and communities about stress, its causes, types, effects, and signs; the available services and resources; and the coping strategies and self-care techniques. Secondary prevention strategies include screening individuals for risk factors or signs of AD; providing counseling, therapy, support groups, crisis intervention, and debriefing to individuals who have been exposed to stress or are at risk of developing AD; and monitoring individuals for changes in behavior or health status. Tertiary prevention strategies include providing medical care, legal assistance, social services, shelter, protection orders, and advocacy to individuals who have developed AD; and facilitating recovery or rehabilitation or reintegration for individuals who have been affected by stress.
- Protection: The nurse should protect the individual’s rights according to the United Nations Declaration of Human Rights. The nurse should respect the individual’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the individual from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment or supplies or medications to prevent or treat complications or infections. The nurse should also protect the individual from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the individual.
- Reporting: The nurse should report any suspected or confirmed cases of stress to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the stress in a clear or concise or objective manner. The nurse should also inform the individual about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the individual to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:

Medical services: such as physician, surgeon, nurse practitioner, physician assistant, nurse, social worker, pharmacist, psychiatrist, psychologist.
Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, victim advocate, guardian ad litem, court-appointed special advocate (CASA).
Social services: such as social worker, case manager, counselor, therapist, support group facilitator, crisis intervention worker, debriefing worker.
Community services: such as stress prevention program, crisis hotline, helpline, support group, peer mentor, mentor, volunteer, faith-based organization.

Education: The nurse should educate the individual about stress prevention and treatment. The nurse should provide accurate or relevant or understandable information about stress or its causes or types or effects or signs; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the individual; and the importance of follow-up and adherence to care.
Support: The nurse should support the individual’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the individual needs or preferences or goals of the individual. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the individual. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the individual. The nurse should also promote the empowerment or resilience or recovery of the individual. The nurse should also involve the family or significant others or community members in the care of the individual as appropriate.
Evaluation: The nurse should evaluate the outcomes of care for the individual. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
- The individual is free from further harm or injury.
- The individual reports or demonstrates reduced pain or discomfort.
- The individual’s physical wounds or infections are healed or treated.
- The individual’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
- The individual reports or demonstrates reduced emotional or behavioral symptoms that are out of proportion to the severity or intensity of the stressor or that impair one’s functioning or relationships.
- The individual reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress.
- The individual reports having a positive outlook on life and a sense of meaning and purpose.
- The individual reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
- The individual reports having a safe and secure environment at home, work, community, or institutional care. The individual reports having a safety plan and protection measures in place.
- The individual reports or demonstrates reduced involvement or exposure to stressors.
- The individual reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
- The individual reports or demonstrates increased adherence to medical care, legal assistance, social services, community services, and follow-up appointments.
- The individual reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.

The nurse should also monitor for any complications or adverse effects of the stress or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the individual. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Adjustment Disorder (AD)

Reactive Attachment Disorder (RAD)

Reactive attachment disorder (RAD) is a mental disorder that develops in early childhood after exposure to severe neglect or abuse or frequent changes in caregivers that prevent the formation of a secure attachment bond with a primary caregiver. RAD is characterized by a consistent pattern of inhibited or emotionally withdrawn behavior toward adult caregivers; a persistent social and emotional disturbance; and an evident lack of having typical childhood experiences of comfort, stimulation, and affection from adult caregivers.
RAD can be classified into two subtypes based on the predominant behavioral pattern: inhibited type and disinhibited type. Inhibited type is marked by a consistent pattern of emotionally withdrawn behavior toward adult caregivers, such as rarely seeking or responding to comfort when distressed, showing minimal social and emotional responsiveness to others, and having a limited positive affect. Disinhibited type is marked by a consistent pattern of indiscriminate social behavior toward adult caregivers, such as showing excessive familiarity or lack of selectivity in choosing attachment figures, approaching strangers in an overly friendly or inappropriate manner, and having difficulty maintaining appropriate boundaries with others.

Clinical Manifestations of RAD

The clinical manifestations of RAD may vary depending on the type and severity and duration and frequency of the neglect or abuse or caregiver changes; the age and developmental stage and personality and coping skills of the child; the availability of social support; the presence of comorbid conditions.
Some of the common clinical manifestations of RAD are:
- Physical signs: such as failure to thrive; growth retardation; developmental delay; malnutrition; dehydration; poor hygiene; chronic illness; infection; injury; pain; fatigue; substance use disorder; suicidal ideation or behavior.
- Psychological signs: such as depression; anxiety; panic disorder; phobias; obsessive-compulsive disorder (OCD); dissociative disorders; personality disorders; eating disorders; sleep disorders.
- Emotional signs: such as fear; anger; guilt; shame; sadness; grief; loneliness; hopelessness; helplessness; low self-esteem; low self-confidence; low self-worth; distrust; resentment; bitterness.
- Behavioral signs: such as withdrawal or isolation or avoidance or detachment or alienation or rejection; aggression or violence or vandalism or theft or lying or cheating or truancy or running away; recklessness or impulsivity or risk-taking; poor performance or attendance or participation in school or work; poor hygiene or grooming; changes in appetite or weight; changes in sleep patterns; substance use disorder; self-harm; suicidal thoughts or behaviors.
- Social signs: such as lack of attachment or bonding or affection or trust or empathy with adult caregivers; lack of social skills or communication skills or interpersonal skills; lack of peer relationships or friendships; lack of involvement or participation in social activities or hobbies or interests; lack of respect or dignity; lack of autonomy or choice.
- Spiritual signs: such as loss of faith or meaning or purpose or values or morals or ethics or hope.

Reactive Attachment Disorder: Symptoms, Treatment

Nursing Assessment of RAD

The nursing assessment of RAD involves collecting subjective and objective data from the child and the caregiver and other sources such as family members, friends, neighbors, teachers, social workers, or health care providers.
The nursing assessment of RAD should be done in a safe, private, and comfortable environment with the child’s consent and cooperation. The nurse should use a calm, gentle, and supportive approach and avoid leading, suggestive, or judgmental questions. The nurse should also use developmentally appropriate language and tools such as dolls, drawings, or games to facilitate communication with the child.
The nursing assessment of RAD should include the following components:
- History: The nurse should obtain a comprehensive history of the child’s physical, mental, emotional, social, and spiritual health and well-being; exposure to neglect or abuse or caregiver changes; current situation and concerns; coping strategies and support systems; strengths and resources.
- Physical examination: The nurse should perform a thorough physical examination of the child’s head, neck, chest, abdomen, back, extremities, genitals, anus, and skin. The nurse should document any signs of injury or trauma or infection or pain or discomfort. The nurse should also assess the child’s vital signs, growth parameters, nutritional status, developmental milestones, pain level, and substance use status.
- Laboratory tests: The nurse should order laboratory tests as indicated by the history and physical examination. Some of the common laboratory tests for RAD are complete blood count (CBC), coagulation studies, electrolytes, liver function tests (LFTs), renal function tests (RFTs), urine analysis (UA), urine toxicology screen (UTS), blood alcohol level (BAL), blood cultures, wound cultures.
- Diagnostic tests: The nurse should order diagnostic tests as indicated by the history and physical examination. Some of the common diagnostic tests for RAD are x-rays, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, ultrasound, electroencephalogram (EEG), electrocardiogram (EKG), echocardiogram.
- Psychological tests: The nurse should administer psychological tests as indicated by the history and physical examination. Some of the common psychological tests for RAD are Reactive Attachment Disorder Questionnaire (RADQ), Randolph Attachment Disorder Questionnaire (RADS), Attachment Behavior Q-Set (ABQ), Attachment Q-Sort (AQS), Strange Situation Procedure (SSP), Attachment Story Completion Task (ASCT), Separation Anxiety Test (SAT), Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR).

Nursing Assessment of RAD

The nursing interventions for RAD are based on the nursing process and evidence-based practice. The nursing interventions for RAD aim to prevent further harm; protect the child’s rights; promote the child’s safety; report the suspected or confirmed neglect or abuse or caregiver changes; refer the child and the caregiver to appropriate services; educate the child and the caregiver about attachment development and disorder; support the child’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for RAD are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of RAD. Primary prevention strategies include providing education, information, and resources to children, caregivers, families, and communities about attachment, its development, importance, types, and signs; the available services and resources; and the coping strategies and self-care techniques. Secondary prevention strategies include screening children and caregivers for risk factors or signs of RAD; providing counseling, therapy, support groups, home visits, crisis intervention, and respite care to children and caregivers who have been exposed to neglect or abuse or caregiver changes or are at risk of developing RAD; and monitoring children and caregivers for changes in behavior or health status. Tertiary prevention strategies include providing medical care, legal assistance, social services, foster care, adoption, kinship care, group homes, residential treatment centers, shelters, protection orders, and advocacy to children who have developed RAD; and facilitating reunification or alternative placement for children who have been removed from their homes due to neglect or abuse or caregiver changes.
- Protection: The nurse should protect the child’s rights according to the United Nations Convention on the Rights of the Child. The nurse should respect the child’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the child from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment, supplies, and medications to prevent or treat complications or infections. The nurse should also protect the child from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the child.
- Reporting: The nurse should report any suspected or confirmed cases of neglect or abuse or caregiver changes to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the neglect or abuse or caregiver changes in a clear, concise, and objective manner. The nurse should also inform the child and the caregiver about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the child and the caregiver to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as pediatrician, surgeon, dentist, ophthalmologist, otolaryngologist, dermatologist, gynecologist, urologist, endocrinologist, neurologist, psychiatrist, psychologist, nurse practitioner, physician assistant, nurse, social worker, pharmacist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, child advocate, guardian ad litem, and court-appointed special advocate (CASA).
  - Social services: such as social worker, case manager, counselor, therapist, support group facilitator, home visitor, crisis intervention worker, respite care worker.
  - Educational services: such as teacher, counselor, tutor, special education teacher, speech therapist, occupational therapist, physical therapist, school nurse, school social worker.
  - Community services: such as attachment disorder prevention program or crisis hotline or helpline or support group or peer mentor or mentor or volunteer or faith-based organization.
- Education: The nurse should educate the child and the caregiver about attachment development and disorder. The nurse should provide accurate or relevant or understandable information about attachment or its development or importance or types or signs; the causes or effects or signs of neglect or abuse or caregiver changes; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the child and the caregiver; and the importance of follow-up and adherence to care.
- Support: The nurse should support the child’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the child’s needs or preferences or goals. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the child. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the child. The nurse should also promote the empowerment or resilience or recovery of the child. The nurse should also involve the family or significant others or community members in the care of the child as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the child and the caregiver. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
  - The child is free from further harm or injury.
  - The child reports or demonstrates reduced pain or discomfort.
  - The child’s physical wounds or infections are healed or treated.
  - The child’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
  - The child reports or demonstrates a consistent pattern of inhibited or emotionally withdrawn behavior toward adult caregivers; a persistent social and emotional disturbance; and an evident lack of having typical childhood experiences of comfort, stimulation, and affection from adult caregivers (inhibited type) OR a consistent pattern of indiscriminate social behavior toward adult caregivers; showing excessive familiarity or lack of selectivity in choosing attachment figures; approaching strangers in an overly friendly or inappropriate manner; and having difficulty maintaining appropriate boundaries with others (disinhibited type).
  - The child reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress.
  - The child reports having a positive outlook on life and a sense of meaning and purpose.
  - The child reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
  - The child reports having a safe and secure environment at home, school, community, or institutional care. The child reports having a safety plan and protection measures in place.
  - The child reports or demonstrates reduced involvement or exposure to neglect or abuse or caregiver changes.

The child reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
The child reports or demonstrates increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments.
The child reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.

The nurse should also monitor for any complications or adverse effects of the neglect or abuse or caregiver changes or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the child and the caregiver. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Reactive Attachment Disorder (RAD)

Disinhibited Social Engagement Disorder (DSED)

Disinhibited social engagement disorder (DSED) is a mental disorder that develops in early childhood after exposure to severe neglect or abuse or frequent changes in caregivers that prevent the formation of a secure attachment bond with a primary caregiver. DSED is characterized by a consistent pattern of indiscriminate social behavior toward adult caregivers; showing excessive familiarity or lack of selectivity in choosing attachment figures; approaching strangers in an overly friendly or inappropriate manner; and having difficulty maintaining appropriate boundaries with others.
DSED is a subtype of reactive attachment disorder (RAD) and shares some common features with it. However, DSED differs from RAD in that children with DSED do not show inhibited or emotionally withdrawn behavior toward adult caregivers; do not have a persistent social and emotional disturbance; and do not lack typical childhood experiences of comfort, stimulation, and affection from adult caregivers.

Clinical Manifestations of DSED

The clinical manifestations of DSED may vary depending on the type and severity and duration and frequency of the neglect or abuse or caregiver changes; the age and developmental stage and personality and coping skills of the child; the availability of social support; the presence of comorbid conditions.
Some of the common clinical manifestations of DSED are:
- Physical signs: such as failure to thrive; growth retardation; developmental delay; malnutrition; dehydration; poor hygiene; chronic illness; infection; injury; pain; fatigue; substance use disorder; suicidal ideation or behavior.
- Psychological signs: such as depression; anxiety; panic disorder; phobias; obsessive-compulsive disorder (OCD); dissociative disorders; personality disorders; eating disorders; sleep disorders.
- Emotional signs: such as fear; anger; guilt; shame; sadness; grief; loneliness; hopelessness; helplessness; low self-esteem; low self-confidence; low self-worth; distrust; resentment; bitterness.
- Behavioral signs: such as withdrawal or isolation or avoidance or detachment or alienation or rejection; aggression or violence or vandalism or theft or lying or cheating or truancy or running away; recklessness or impulsivity or risk-taking; poor performance or attendance or participation in school or work; poor hygiene or grooming; changes in appetite or weight; changes in sleep patterns; substance use disorder; self-harm; suicidal thoughts or behaviors.
- Social signs: such as lack of attachment or bonding or affection or trust or empathy with adult caregivers; lack of social skills or communication skills or interpersonal skills; lack of peer relationships or friendships; lack of involvement or participation in social activities or hobbies or interests; lack of respect or dignity; lack of autonomy or choice.
- Spiritual signs: such as loss of faith or meaning or purpose or values or morals or ethics or hope.

Nursing Assessment of DSED

The nursing assessment of DSED involves collecting subjective and objective data from the child and the caregiver and other sources such as family members, friends, neighbors, teachers, social workers, or health care providers.
The nursing assessment of DSED should be done in a safe, private, and comfortable environment with the child’s consent and cooperation. The nurse should use a calm, gentle, and supportive approach and avoid leading, suggestive, or judgmental questions. The nurse should also use developmentally appropriate language and tools such as dolls, drawings, or games to facilitate communication with the child.
The nursing assessment of DSED should include the following components:
- History: The nurse should obtain a comprehensive history of the child’s physical, mental, emotional, social, and spiritual health and well-being; exposure to neglect or abuse or caregiver changes; current situation and concerns; coping strategies and support systems; strengths and resources.
- Physical examination: The nurse should perform a thorough physical examination of the child’s head, neck, chest, abdomen, back, extremities, genitals, anus, and skin. The nurse should document any signs of injury trauma or infection pain or discomfort. The nurse should also assess the child’s vital signs, growth parameters, nutritional status, developmental milestones, pain level, and substance use status.
- Laboratory tests: The nurse should order laboratory tests as indicated by the history and physical examination. Some of the common laboratory tests for DSED are complete blood count (CBC), coagulation studies, electrolytes, liver function tests (LFTs), renal function tests (RFTs), urine analysis (UA), urine toxicology screen (UTS), blood alcohol level (BAL), blood cultures, wound cultures.
- Diagnostic tests: The nurse should order diagnostic tests as indicated by the history and physical examination. Some of the common diagnostic tests for DSED are X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, ultrasound, electroencephalogram (EEG), electrocardiogram (EKG), and echocardiogram.
- Psychological tests: The nurse should administer psychological tests as indicated by the history and physical examination. Some of the common psychological tests for DSED are Disinhibited Social Engagement Disorder Questionnaire (DSEDQ), Disinhibited Social Engagement Disorder Interview (DSEDI), Structured Clinical Interview for DSM-5 Disorders (SCID-5), Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR).

Nursing Interventions for DSED

The nursing interventions for DSED are based on the nursing process and evidence-based practice. The nursing interventions for DSED aim to prevent further harm; protect the child’s rights; promote the child’s safety; report the suspected or confirmed neglect or abuse or caregiver changes; refer the child and the caregiver to appropriate services; educate the child and the caregiver about attachment development and disorder; support the child’s physical, mental, emotional, social, and spiritual healing; and evaluate the outcomes of care.
Some of the common nursing interventions for DSED are:
- Prevention: The nurse should implement primary, secondary, and tertiary prevention strategies to reduce the risk of DSED. Primary prevention strategies include providing education, information, and resources to children, caregivers, families, and communities about attachment, its development, importance, types, and signs; the available services and resources; and the coping strategies and self-care techniques. Secondary prevention strategies include screening children and caregivers for risk factors or signs of DSED; providing counseling, therapy, support groups, home visits, crisis intervention, and respite care to children and caregivers who have been exposed to neglect or abuse or caregiver changes or are at risk of developing DSED; and monitoring children and caregivers for changes in behavior or health status. Tertiary prevention strategies include providing medical care, legal assistance, social services, foster care, adoption, kinship care, group home, residential treatment center, shelter, protection orders, and advocacy to children who have developed DSED; and facilitating reunification or alternative placement for children who have been removed from their homes due to neglect or abuse or caregiver changes.
- Protection: The nurse should protect the child’s rights according to the United Nations Convention on the Rights of the Child. The nurse should respect the child’s dignity, autonomy, privacy, confidentiality, and participation in decision-making. The nurse should also protect the child from further harm by ensuring a safe and secure environment; removing or minimizing any potential sources of danger; and providing appropriate equipment or supplies or medications to prevent or treat complications or infections. The nurse should also protect the child from re-traumatization by avoiding unnecessary or repeated examinations or procedures; using a trauma-informed approach; and providing emotional support and comfort to the child.
- Reporting: The nurse should report any suspected or confirmed cases of neglect or abuse or caregiver changes to the appropriate authorities as mandated by the law and the professional code of ethics. The nurse should follow the reporting protocol of the institution or agency where he or she works. The nurse should document the facts and evidence of the neglect or abuse or caregiver changes in a clear, concise, and objective manner. The nurse should also inform the child and the caregiver about the reporting process and their rights and responsibilities. The nurse should cooperate with the investigation and provide any additional information or testimony as required.
- Referral: The nurse should refer the child and the caregiver to appropriate services that can provide further assessment, treatment, support, and follow-up. Some of the common services that the nurse can refer to are:
  - Medical services: such as pediatrician, surgeon, dentist, ophthalmologist, otolaryngologist, dermatologist, gynecologist, urologist, endocrinologist, neurologist, psychiatrist, psychologist, nurse practitioner, physician assistant, nurse, social worker, pharmacist.
  - Legal services: such as lawyer, judge, prosecutor, defense attorney, police officer, detective, forensic examiner, child advocate, guardian ad litem, court-appointed special advocate (CASA).
  - Social services: such as social worker, case manager, counselor, therapist, support group facilitator, home visitor, crisis intervention worker, respite care worker.
  - Educational services: such as teacher, counselor, tutor, special education teacher, speech therapist, occupational therapist, physical therapist, school nurse, school social worker.
  - Community services: such as attachment disorder prevention program or crisis hotline or helpline or support group or peer mentor or mentor or volunteer or faith-based organization.
- Education: The nurse should educate the child and the caregiver about attachment development and disorder. The nurse should provide accurate or relevant or understandable information about attachment or its development or importance or types or signs; the causes or effects or signs of neglect or abuse or caregiver changes; the reporting process and legal implications; the available services and resources; the treatment options and outcomes; the coping strategies and self-care techniques; the safety planning and protection measures; the rights and responsibilities of the child and the caregiver; and the importance of follow-up and adherence to care.
- Support: The nurse should support the child’s physical or mental or emotional or social or spiritual healing. The nurse should provide holistic and culturally sensitive care that meets the child’s needs or preferences or goals. The nurse should also provide therapeutic communication or active listening or empathy or validation or encouragement or praise to the child. The nurse should also facilitate the development of a trusting or respectful or collaborative relationship with the child. The nurse should also promote the empowerment or resilience or recovery of the child. The nurse should also involve the family or significant others or community members in the care of the child as appropriate.
- Evaluation: The nurse should evaluate the outcomes of care for the child and the caregiver. The nurse should use standardized tools or scales or questionnaires or interviews or observations to measure the progress or improvement or achievement of the expected outcomes. The expected outcomes may include:
  - The child is free from further harm or injury.
  - The child reports or demonstrates reduced pain or discomfort.
  - The child’s physical wounds or infections are healed or treated.
  - The child’s vital signs or laboratory tests or diagnostic tests are within normal limits or show improvement.
  - The child reports or demonstrates a consistent pattern of indiscriminate social behavior toward adult caregivers; showing excessive familiarity or lack of selectivity in choosing attachment figures; approaching strangers in an overly friendly or inappropriate manner; and having difficulty maintaining appropriate boundaries with others.
  - The child reports or demonstrates increased happiness or confidence or self-worth or self-esteem or social skills or trust in others or expression of emotions or coping with stress.
  - The child reports having a positive outlook on life and a sense of meaning and purpose.
  - The child reports having a supportive network of family members, friends, peers, mentors, professionals, and community members.
  - The child reports having a safe and secure environment at home, school, community, or institutional care. The child reports having a safety plan and protection measures in place.
  - The child reports or demonstrates reduced involvement or exposure to neglect or abuse or caregiver changes.

The child reports or demonstrates increased involvement or participation in positive activities or hobbies or interests or goals.
The child reports or demonstrates increased adherence to medical care, legal assistance, social services, educational services, community services, and follow-up appointments.
The child reports or demonstrates increased satisfaction with the quality of care and the relationship with the nurse and other professionals.

The nurse should also monitor for any complications or adverse effects of the neglect or abuse or caregiver changes or the treatment such as infection, bleeding, shock, organ failure, sepsis, death, re-injury, re-victimization, re-traumatization, non-compliance, relapse, recurrence, dissatisfaction.
The nurse should also modify the plan of care as needed based on the evaluation of the outcomes and the feedback from the child and the caregiver. The nurse should also collaborate with other members of the interdisciplinary team to ensure continuity and coordination of care. The nurse should also document the evaluation of the outcomes and any changes in the plan of care in a clear, concise, and objective manner.

Take Practice Test on Disinhibited Social Engagement Disorder (DSED)

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