Medical and psychosocial aspects, with crisis and trauma

A VR agency adopts trauma-informed care. Which practice change best reflects this approach?

1. requiring trauma disclosure at every intake
   Requiring disclosure can retraumatize; trauma-informed services respect a person's choice about what to share.
2. explaining procedures and offering choices
   Trauma-informed care emphasizes safety, trustworthiness, choice, and collaboration, so explaining what will happen and offering choices puts it into practice.
3. referring every trauma survivor to psychiatry
   Not every survivor needs psychiatric care; blanket referral pathologizes normal responses and ignores individual choice.
4. using restraint quickly when clients are upset
   Quick use of restraint is a common retraumatizing practice that trauma-informed care tries to reduce.

The polytrauma clinical triad frequently seen in post-9/11 combat veterans consists of TBI, PTSD, and:

1. hearing loss
   Hearing loss and tinnitus are frequent blast injuries, but they are not part of the clinical triad.
2. chronic pain
   The polytrauma clinical triad described in post-9/11 veterans is TBI, PTSD, and chronic pain, which often overlap and complicate rehabilitation.
3. substance use disorder
   Substance use often co-occurs, but the triad's third element is chronic pain.
4. major depression
   Depression is common in this group, but it is not part of the named triad.

During a crisis session, a client with a moderate TBI becomes agitated and confused. The counselor should:

1. confront the agitation firmly to set limits
   Firm confrontation raises arousal and tends to escalate agitation after a brain injury.
2. use metaphors to explain new coping strategies
   Metaphors are abstract, and a confused person with a TBI tends to process language literally.
3. teach several coping skills during the session
   Teaching several skills at once overloads impaired attention and memory during a crisis.
4. lower stimulation and give one direction at a time
   After a TBI, agitation and confusion worsen with overload, so the counselor reduces noise and demands and gives short, single-step directions.

After an explosion at a plant, a counselor must prioritize among distressed workers. Who needs attention FIRST?

1. a disoriented worker who cannot respond
   In psychological first aid triage, people who are disoriented or unresponsive come first because they may be injured or in acute stress and cannot look after themselves.
2. a worker crying about a hurt friend
   Crying is a normal grief response; this worker can communicate and is not the highest priority.
3. a worker asking when he can go home
   Asking practical questions shows he is oriented and functioning.
4. a worker angry at management
   Anger is a common, expected reaction; this worker is oriented and can wait for the more impaired one.

Three days after a flood, a survivor reports flashbacks, jumpiness, and poor sleep but is safe and functioning. The most appropriate response is to:

1. normalize reactions and monitor with support
   In the first days after a disaster, intrusive memories and poor sleep are common and often fade, so psychological first aid normalizes reactions, supports coping, and monitors for persistence.
2. hold a detailed debriefing of the flood
   Detailed single-session debriefing has not been shown to prevent PTSD and may harm some survivors.
3. diagnose PTSD and begin exposure therapy
   PTSD requires symptoms lasting more than a month; three days after the flood is too early, and exposure therapy is not first-line acute care.
4. refer immediately for sleep medication
   Poor sleep is expected acutely; immediate medication referral medicalizes a normal reaction in someone who is safe and functioning.

At each session, a counselor tells a client who uses a wheelchair that he is 'so inspiring' for coming to appointments on his own. This behavior is best described as:

1. cultural humility
   Cultural humility means examining one's own assumptions; repeating a stereotype at every session shows the opposite.
2. a microaggression
   Calling someone 'inspiring' for ordinary tasks is a disability microaggression: it implies low expectations of people with disabilities and treats the person as a symbol, not a client.
3. the requirement of mourning
   Wright's requirement of mourning is the expectation that a person with a disability should suffer and grieve; praise for being inspiring is a different stereotype.
4. unconditional positive regard
   Unconditional positive regard is acceptance of the whole person, not praise for routine acts because of a disability.

A client's medical report lists peripheral neuropathy as a complication of diabetes. The counselor should expect:

1. reduced sensation in the feet and hands
   Diabetic peripheral neuropathy damages peripheral nerves, typically starting in the feet and then the hands, causing numbness, tingling, or burning and a higher risk of unnoticed injuries.
2. frequent low blood sugar during the workday
   Hypoglycemia comes from diabetes treatment and timing of meals, not from nerve damage.
3. reduced kidney function that may require dialysis
   Kidney damage is diabetic nephropathy, a separate complication that the report does not list.
4. loss of central vision from retinal damage
   Retinal damage is diabetic retinopathy, a different complication; neuropathy affects nerves, not the retina.

Months after a transfemoral amputation, a client reports burning pain that he feels in his missing foot. This is:

1. residual limb pain
   Residual limb pain is felt in the remaining stump, for example from a neuroma or a poor socket fit, not in the missing foot.
2. referred sciatic pain
   Referred sciatic pain follows a nerve root irritated in the back; the stem places the pain in the missing foot after amputation.
3. phantom limb sensation
   Phantom limb sensation covers nonpainful feelings, such as tingling or position, in the missing part; burning pain is phantom pain.
4. phantom limb pain
   Phantom limb pain is painful sensation, such as burning or cramping, felt in the part of the limb that is gone.

A worker recovering from a back injury receives more attention from his family and avoids a job he disliked, and these rewards seem to be prolonging his disability. This is:

1. primary gain
   Primary gain is the internal psychological relief a symptom provides, not external rewards such as attention or time off.
2. secondary gain
   Secondary gain means external advantages of being disabled, such as attention or avoiding a disliked job, that may unintentionally prolong disability.
3. conscious malingering
   Malingering is intentional faking; secondary gain can operate without any deliberate deception.
4. tertiary gain
   Tertiary gain is the benefit someone else gets from the person's illness, such as a caregiver's sense of purpose.

The parents of a 22-year-old with cerebral palsy do his daily tasks for him and discourage him from living on his own, even though he has the skills. This family pattern is best described as:

1. disengagement
   Disengagement is too much distance and too little involvement, the opposite of this family's pattern.
2. parentification
   Parentification gives a child adult caregiving duties; here the parents keep doing his tasks for him.
3. triangulation
   Triangulation pulls a third person into a conflict between two others; the stem describes no such conflict.
4. overprotection
   Doing tasks he can do himself and discouraging independence is overprotection, a common family response to disability that limits autonomy.

A client with coronary artery disease gets chest pain during heavy exertion that stops within minutes of rest or nitroglycerin. This is:

1. congestive heart failure
   Heart failure causes breathlessness, fatigue, and fluid buildup, not brief exertional chest pain that stops with rest.
2. myocardial infarction
   A heart attack causes lasting pain with heart muscle damage, and rest or nitroglycerin does not quickly relieve it.
3. stable angina
   Stable angina is predictable chest pain with exertion that goes away within minutes of rest or nitroglycerin.
4. unstable angina
   Unstable angina is new, worsening, or at-rest chest pain and is a medical emergency; this pain is predictable and relieved.

A client with a frontal-lobe TBI has angry outbursts at work because he does not notice his rising irritation. Counseling should emphasize:

1. concrete strategies with external cues.
   Frontal-lobe injury impairs self-monitoring, so concrete routines with external cues, such as timers or a signal from a coworker, work better than insight alone.
2. unstructured, nondirective talk.
   Unstructured approaches give too little structure to someone with executive dysfunction.
3. insight into the anger's roots.
   Insight work assumes he can notice and reflect on his emotions, which is exactly what his frontal injury impairs.
4. abstract disputation of angry thoughts.
   Abstract disputation of thoughts needs reasoning and self-monitoring skills that a frontal-lobe injury disrupts.

In the ICF, a supervisor's supportive attitude that helps a client with bipolar disorder keep her job is classified as:

1. a body function
   Body functions are physiological and mental functions, such as mood regulation, not workplace attitudes.
2. an environmental factor
   In the ICF, environmental factors include other people's attitudes and support, and a supportive supervisor acts as a facilitator.
3. a personal factor
   Personal factors are features of the individual, such as age, coping style, or education, not the attitudes of others.
4. a participation restriction
   A participation restriction is a problem in life situations, such as losing a job; the supervisor's support helps prevent it.

A 52-year-old reports symmetrical swelling of the small joints of both hands, morning stiffness lasting over an hour, and fatigue. This presentation is MOST consistent with:

1. fibromyalgia syndrome
   Fibromyalgia causes widespread pain and fatigue but no joint swelling.
2. osteoarthritis
   Osteoarthritis is wear-related, often asymmetric, with morning stiffness under about 30 minutes.
3. rheumatoid arthritis
   RA is an autoimmune disease that affects small joints symmetrically, with morning stiffness lasting over an hour and systemic fatigue.
4. gouty arthritis
   Gout usually causes sudden attacks in one joint, often the big toe, not symmetric swelling of the hands.

After a heart attack, a client has low stamina, fears that exertion will cause another attack, and is withdrawing socially. The MOST appropriate program is:

1. outpatient cardiac rehabilitation
   Outpatient cardiac rehab combines supervised exercise, education, and psychosocial support, addressing both his stamina and his fear of exertion.
2. an interdisciplinary pain program
   An interdisciplinary pain program treats chronic pain, which the stem does not describe.
3. a work hardening program
   Work hardening simulates job demands for return to work; he first needs medically supervised conditioning.
4. pulmonary rehabilitation
   Pulmonary rehab is designed for lung disease such as COPD, not recovery after a heart attack.

A client with multiple sclerosis notices that her blurred vision and leg weakness worsen after hot showers or exercise and ease once she cools down. This is:

1. a new MS relapse
   A relapse lasts at least 24 hours without fever or overheating; symptoms that ease once she cools down are a pseudo-relapse.
2. spasticity triggered by exertion
   Spasticity is muscle stiffness; it does not explain blurred vision, and heat is the trigger here, not effort itself.
3. Lhermitte's sign
   Lhermitte's sign is an electric sensation down the spine when bending the neck, not heat-triggered blurred vision.
4. Uhthoff's phenomenon
   Uhthoff's phenomenon is a temporary worsening of MS symptoms with heat that resolves when the body cools; it is not new damage.

A client with COPD panics when he gets short of breath and now avoids almost all physical activity. The MOST appropriate intervention is:

1. avoiding exertion until his breathing improves
   Avoidance leads to deconditioning and worse breathlessness, which keeps the panic cycle going.
2. a sedative taken before any physical activity
   Sedatives can depress breathing in COPD and do not teach control of breathlessness.
3. pulmonary rehab with breathing retraining
   Pulmonary rehab with breathing retraining, such as pursed-lip breathing, builds tolerance and breaks the cycle of breathlessness, panic, and avoidance.
4. a work hardening program focused on lifting
   Lifting-focused work hardening is premature; his problem is breathlessness and panic during activity.

A client with a below-knee amputation says, 'What makes me worth something is being a good father and teacher, not how my body looks.' Wright would describe this as:

1. containing disability effects
   Containment keeps the disability from spreading to judgments of the whole person; he is reordering values, not limiting spread.
2. enlarging the scope of values
   Enlarging the scope of values means recognizing values beyond those lost; his statement ranks body image below other values, which is subordination.
3. subordinating physique relative to other values
   Saying his worth lies in being a father and teacher rather than in his body shows Wright's subordination of physique: appearance and physical ability matter less than other values.
4. moving from asset values toward comparative values
   Wright's shift runs the other way, from comparative values, measured against a norm, toward asset values.