멘탈헬스 2

The nurse is teaching a victim of intimate violence how to create a safety plan. Which should be included when the nurse is assiting the client in devising an escape? Select all that apply.

prepare and hide an escape bag map the house for an escape route identify a prearranged place for children to meet configure a list telephone numbers needed in case of emergency

The nurse is planning care for a client who is a victim of violence. Which of the following should the nurse identify as goals for this client's plan of care? Select all that apply.

ensure safety prevent injury restore health stop the violence

The nurse is approached by a teacher who suspects a student is being neglected after observing changes in the student's behavior. The teacher asks the nurse what other behaviors to watch for. Which symptoms of neglect should the nurse include in the discussion ? Select all that apply.

fighting with other students deteriorating grades in school smoking a cigarette after school refusing to answer when called on in class

The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to

have their needs met.

The nurse is teaching a victim of intimate violence how to create a safety plan. Which should be included when the nurse is assisting the client in devising an escape? Select all that apply.

prepare and hide an escape bag; map the house for an escape route; identify a prearranged place for children to meet; configure a list telephone numbers needed in case of emergency

Which assessment question should the nurse ask of a client suspected of being ostracized by a school bully?

"Do you feel like a part of a group in school?"

A middle-aged client with young children has been the victim of intimate partner violence (IPV). When providing initial care to this family, the nurse should:

carefully assess the children for signs of trauma.

The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment?

child crying and appearing sad

A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer?

"Actually, fewer than 2% of all reported rapes are found to be false."

An aggressive client gets hold of a glass piece and prevents anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply.

-Summon help from others -Leave the area immediately -Shift other clients to a safe place

A client is brought to the Emergency Department by a family member that reports being sexually assaulted while leaving work. What action by the nurse would best promote placing control back to the client?

Allow the client to make decisions regarding care whenever possible

A nurse is preparing to gather a health history of a client. Which questions can elicit disclosure if a client has been abused? Select all that apply.

"When there are arguments at home, have you ever been hurt or afraid?"; "It looks like someone has hurt you. Tell me about it."; "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it."

A psychiatric-mental health nurse is teaching a class for a group of colleagues about anger, aggression, and violence. Which statement by the nurse would be most appropriate to include?

"Women experience anger as frequently as men do."

The nurse is planning treatment for a client with aggressive and psychotic behavior. What should be the immediate goals of treatment for this client? Select all that apply.

-The client will not harm the self. -The client will demonstrate decreased acting out behavior. -The client will withhold from harming others or damaging the hospital property.

A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer? "Actually, fewer than 2% of all reported rapes are found to be false." "I'm not sure where you heard that but statistically it isn't true." "I don't believe that's true but even if it were it doesn't excuse the real rapes that occur." "If a man is falsely accused, the woman is prosecuted by the law."

"Actually, fewer than 2% of all reported rapes are found to be false." Explanation: Rape is an underreported crime due to feelings of guilt on the part of the victim. Only approximately 2% of all reported rape cases are false.

Which assessment question should the nurse ask of a client suspected of being ostracized by a school bully? "Do you feel like a part of a group in school?" "Do you smoke or use drugs?" "Can you go to the school principal with personal problems?" "Have you talked to your parents about your problems at school?"

"Do you feel like a part of a group in school?" Explanation: Ostracism, ignoring and excluding a target individual, has recently emerged as one of the more common and damaging forms of bullying. The victim experiences threats to belonging, self-esteem, meaningful existence, and sense of control. Ostracism may pose an even greater threat to children's adjustment than bullying. Those who bully are more likely to have poor grades and to use alcohol and tobacco. None of the remaining options are directly associated with the issue of ostracizing.

A person brings a parent to the clinic and tells the nurse that the parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for the outburst. The person says, "I've never seen my parent act this way." Which question would be most appropriate for the nurse to ask next?

"Has your parent suffered any traumatic injury to the brain recently?"

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

"He tells me that he is sorry and that he will never hit me again."

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? "He threw me against the wall and started punching my face." "He yells at me for not having dinner waiting for him when he comes home." "He calls me stupid and incompetent, asking himself why he ever married me." "He tells me that he is sorry and that he will never hit me again."

"He tells me that he is sorry and that he will never hit me again." Explanation: During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1, or tension building.

The nurse is caring for a client with rheumatoid arthritis. Upon entering the client's room, the nurse finds that the client is very angry and is punching pillows to express the anger. What should be the nurse's response to this behavior?

"I am here so we can talk about what is making you angry."

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence?

"I don't know what else I can do to keep him from getting angry at me."

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence? "He was so much nicer when we started dating." "His father physically abused his mother for years." "He doesn't like it when I go out with my girlfriends." "I don't know what else I can do to keep him from getting angry at me."

"I don't know what else I can do to keep him from getting angry at me." Explanation: A warning sign of relationship violence is feeling that you must change your life or yourself so you won't anger him or her. The remaining statements, while troublesome, are not as clearly associated with behaviors of violence.

Which statement, made by a nurse who experienced sexual abuse as as a child, demonstrates being best prepared to work with sexual abuse and trauma survivors?

"I've been supported by health care professionals and now I want to support other survivors."

A nurse is working with a client who is a survivor of rape. The client asks the nurse, "It's been 6 months since it happened. Why can't I get back into doing the things I did before?" What is the nurse's best response?

"It can take at least a year or more to get back to where you were before.

A nurse is working with a client who is a survivor of rape. The client asks the nurse, "It's been 6 months since it happened. Why can't I get back into doing the things I did before?" What is the nurse's best response? "Life is different for you now, you will gradually accept that." "It can take at least a year or more to get back to where you were before." "You are a victim. You need to give yourself some time." "Let's talk about what happened to you again. It can help."

"It can take at least a year or more to get back to where you were before." Explanation: It often takes one or more year for survivors of rape to regain previous levels of functioning. It is important to remind clients that it is possible to return to previous levels of functioning. Clients have many strengths that they don't realize. It is important for the nurse to avoid using the word "victim" and help the client identify as a survivor. The nurse should help the client focus on the present rather than dwell on horrific things from the past.

An emergency department nurse is assessing a client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?

"It looks like someone has hurt you. Tell me about it."

An emergency department nurse is assessing a client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? "Is your partner being mean to you?" "Why do you think your spouse has beaten you?" "It looks like someone has hurt you. Tell me about it." "Can you describe the person who did this to you?"

"It looks like someone has hurt you. Tell me about it." Explanation: The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize thoughts and feelings. Asking whether the partner is being mean or asking why the client thinks the spouse has done this beating assumes that the client has been abused. Asking about the person who did this would be ineffective because survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly.

The nurse is caring for a client with aggressive behavior. The client tells the nurse, "I am feeling extremely angry. I feel like breaking the windows in here." What would be the most appropriate response of the nurse?

"Let's go to the gym and exercise."

The nurse is concerned that a victim of intimate violence is experiencing revictimization. Which client statement leads the nurse to this assessment? Select all that apply.

"My parents used marijuana and cocaine."; "My uncle sexually abused me when I was 8 years old."; "I smoke marijuana and have several cocktails in the evening."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"My partner tells me that he or she will tell child services I'm a bad parent."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this? "My partner always tells me that the abuse never happened." "My partner tells me who I can and cannot see." "My partner tells me that he or she will tell child services I'm a bad parent." "My partner acts like the master of the castle and I'm the servant."

"My partner tells me that he or she will tell child services I'm a bad parent." Explanation: The statement about telling child services that the client is a bad parent reflects coercion and threats. The statement about the abuse never happening reflects power and control through minimizing, denying, and blaming. The statement about whom the client can and cannot see reflects power and control through the use of isolation. The statement about the partner being the master of the castle reflects power and control through the use of privilege.

A client has been in a physically abusive relationship for more than a decade. Which statement best demonstrates that the client understands of how fear can influence a reluctance to leave such a relationship?

"My partner would hunt me down and kill me for sure."

While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression?

"People say I withdraw and pout about the problem."

A nurse is presenting to a church group a program about domestic violence. During the presentation, a member of the audience asks the nurse to explain what "intergenerational transmission of violence" means because the person has seen that phrase used in the media. Which response by the nurse would be most appropriate?

"People who grow up in violent home situations tend to be involved in domestic violence situations as an adult."

The nurse prepares a community program for survivors of intimate partner violence. Which of the folowing statements made by a participant indicates the need for further teaching? Select all that apply.

"Survivors of intimate partner violence may experience loss of apetite." "Difficulty in the work place may occur related to distractability and confusion ." Urticaria is sometimes a result of the anxiety experienced by survivors of intimate partner violence."

The nurse is providing care to client who is currently in a sexually abusive relationship. To best manage the development of additional comorbid disorders, what question(s) should the nurse ask this client? Select all that apply.

"What community resources related to HIV and pregnancy are you aware of?" "What are the early symptoms of posttraumatic stress disorder (PTSD)?" "Are you aware of self-defense strategies to physically protect oneself?" "Do you have a safety and escape plan in place?"

A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate?

"What works best is what fits the client and the situation."

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?

"You have the right to be safe and respected."

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client? "You have the right to be safe and respected." "Relationship counseling can be very helpful." "I wonder if your perceptions of the relationship are accurate." "I am here to help you through every step of this process."

"You have the right to be safe and respected." Explanation: When working with someone who is a victim of partner abuse, it is important that the nurse assertively support the client's decision. The affirmation of the client's decision can help to improve the client's self-confidence as she begin the process of leaving her partner. It is important the nurse refrain from recommending couple's counseling, imply doubt about the client's situation, or take charge and do everything for the client.

A nurse is preparing to gather a health history of a client. Which questions can elicit disclosure if a client has been abused? Select all that apply. "When there are arguments at home, have you ever been hurt or afraid?" "It looks like someone has hurt you. Tell me about it." "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it." "I don't believe you. Why don't you tell me the truth?" "It appears that you are distracted. Let me know when you are ready to discuss the incident."

- "When there are arguments at home, have you ever been hurt or afraid?" - "It looks like someone has hurt you. Tell me about it." - "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it." Explanation: The U.S. Preventive Service Task Force recommends routine screening to detect current or past abuse, and risk of abuse. Most survivors do not report violence to health care workers without being specifically asked about it. Survivors may be reluctant to report abuse due to shame and fear of retaliation. Asking specific abuse screening questions has been shown to increase the detection of abuse substantially. Questions should be open ended and clients may need time to disclose the abuse. Clients need to know the nurse is listening, believes them and is concerned for their safety and well-being. Asking the client about telling the nurse the truth means the nurse does not believe them. By telling the client they are distracted, the nurse is not allowing time for the victim to discuss at their own pace.

A nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her son 48 years of age. Which of the following would be most important for the nurse to keep in mind before interviewing the family?

The nurse must allow the older adult mother to decide whether she wants to leave the situation.

During an interview, a client reveals to the nurse, "I was sexually abused as a child." Based on this information, which finding would the nurse most likely anticipate being revealed during the assessment? Select all that apply. Client has difficulty establishing interpersonal relationships Client has a history of substance abuse Client has difficulty establishing a mutually satisfying sexual relationship Client engages in self-harming behaviors Client exhibits antisocial tendencies

- Client has difficulty establishing interpersonal relationships - Client has a history of substance abuse - Client has difficulty establishing a mutually satisfying sexual relationship - Client engages in self-harming behaviors Explanation: Losing the ability to trust people is a common characteristic of the adult survivor of childhood sexual abuse. Substance abuse is a common characteristic of the adult survivor of childhood sexual abuse. Other characteristics include having difficulty establishing interpersonal relationships and finding mutually satisfying sexual relationships. Also, survivors may engage in self-harm.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?

Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.

A nurse is preparing a presentation for a senior center about elder abuse. When describing individuals associated with abusing older adults, which group would the nurse most likely identify? Select all that apply. Family member Adults Children Spouses Friends

- Family member - Adults - Children - Spouses Explanation: Family members, adults, children, or spouses are implicated in 90% of the cases of elder abuse

The nurse is preparing a teaching plan for a client who experiences intimate partner violence. Which topics should the nurse include? Select all that apply. HIV testing sleep hygiene access to shelters nutritional support employment counseling

- HIV testing - sleep hygiene - access to shelters - nutritional support Explanation: When caring for the client who has been abused, the nurse teaching plan should include information about HIV testing, sleep hygiene, access to shelters, and adequate nutrition. Employment counseling is not identified as a topic when teaching the client who has been abused.

The nurse is caring for a client with aggression disorder. The client has an anger episode and is threatening other clients in the emergency room with a knife. What should be the approach of the nurse in this situation? Select all that apply.

-The nurse should attempt to kick the knife out of the client's hand. -The nurse should call for outside assistance.

The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply. The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection There are frequent ear infections

- The anal area is bruised - The child reports "itching down there" - The vulva appears edematous - The urinalysis reports a bacterial infection Explanation: The nurse's suspicion that a child has been sexually abused is supported when the assessment data includes a bruised anal area, itching reported by the child, an edematous vulva, and a urinary infection. Ear infections are common among children.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply. The client is embarrassed of the assault. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim. The victim is responsible for the attack. The person is concerned about the financial issues associated with the hospitalization.

- The client is embarrassed of the assault. - They have a fear of being blamed for the incident. - The perpetrator may use coercion or threats to control the victim. Explanation: Fewer than half of rapes and sexual assaults are reported, generally because of shame, embarrassment, concern about not being believed or fear of being blamed for the assault. Knowing the attacker may also be a factor that inhibits reporting. The majority of sexual violence is perpetrated by intimate partner or acquaintances and does nto involve weapons or severe physical violence. The perpetrator may use coercion, threats, or substances to control the victim. The nurse needs to understand these reasons to develop a therapeutic relationship to assist in the care of the client victim.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply. The client is embarrassed of the assault. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim. The victim is responsible for the attack. The person is concerned about the financial issues associated with the hospitalization.

- The client is embarrassed of the assault. - They have a fear of being blamed for the incident. - The perpetrator may use coercion or threats to control the victim. Explanation: Fewer than half of rapes and sexual assaults are reported, generally because of shame, embarrassment, concern about not being believed or fear of being blamed for the assault. Knowing the attacker may also be a factor that inhibits reporting. The majority of sexual violence is perpetrated by intimate partner or acquaintances and does nto involve weapons or severe physical violence. The perpetrator may use coercion, threats, or substances to control the victim. The nurse needs to understand these reasons to develop a therapeutic relationship to assist in the care of the client victim.

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply. The client is physically dependent on the client's son since losing mobility. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." The client and client's child are recent immigrants to the United States. The client self-describes and describes the client's child as "not well-off, but not terribly poor either."

- The client is physically dependent on the client's son since losing mobility. - The client has no income or savings of the client's own. - The client's son describes the client as "needy, helpless, and pathetic." Explanation: Physical and financial dependence and personality conflicts with caregivers and children are known to contribute to elder abuse. Low socioeconomic status and recent immigration are not identified as causative factors.

A client who has a history of hostile behavior appears severely agitated. What interventions should the nurse perform to prevent harm to the client and others? Select all that apply.

-Obtain orders for seclusion if needed. -Make arrangements for possible restraint. -Anticipate the use of sedatives. -Use a low calm voice

Under which circumstances can an expression of anger be considered a normal and healthy reaction? Select all that apply.

-When facing an unjust situation. -When personal rights are not respected. -When realistic expectations are not met.

The nurse is planning a community education session on elder abuse awareness. Which points should the nurse be sure to include? (Select all that apply.) Withholding money for necessities is a form of abuse Not helping you get medical attention you need is a form of abuse It is abuse if you feel forced to have sex It is abuse if your caregiver holds your arm too tight If you are arguing constantly with a family member, it is a form of abuse

- Withholding money for necessities is a form of abuse - Not helping you get medical attention you need is a form of abuse - It is abuse if you feel forced to have sex - It is abuse if your caregiver holds your arm too tight Explanation: Elder abuse is the maltreatment of older adults by family members or others in a caregiver role. It may include physical and sexual abuse and denial of adequate medical treatment, among others. Arguing constantly is not a form of elder abuse.

The nurse suspects that a client is a victim of intimate partner violence. What should the nurse consider when caring for this client? Select all that apply. cost-effective care availability of support legal counsel is obtained family counseling is provided support can be accessed safely

- availability of support - support can be accessed safely Explanation: The challenge for health care providers is twofold—ensuring that support is both available and safely accessible. Many victims of intimate partner violence are afraid or reluctant to identify their abusers, fearing retaliation against themselves and/or their children. They may continue to hold strong feelings for their partners despite the abuse. When medical care is required, women may attribute their injuries to other causes; health care providers may be reluctant to inquire about abuse. Provision of assistance to clients who are involved in violent intimate relationships can pose unique problems in that seeking support can be dangerous to the women if their activities are discovered by the abusive partner. Cost of care, legal counsel, and family counseling are not areas for consideration for a client suspected of being a victim of intimate violence.

The nurse is assessing a client and suspects that the client is a victim of intimate partner violence. The client is experiencing palpatations. What additional findings should the nurse assess the client for related to intimate partner violence? Select all that apply. missing teeth low blood pressure inability to fully extend the right leg wearing clothing inappropriate for the weather variety of wounds in different stages of healing

- missing teeth - inability to fully extend the right leg - wearing clothing inappropriate for the weather - variety of wounds in different stages of healing Explanation: Physical findings that can suggest abuse include missing teeth and limited range of motion in an extremity. Wearing clothes that are inappropriate for the weather could be an action to hide bruises or wounds. Various wounds in different stages of healing could indicate repeated episodes of abuse. An elevated blood pressure is associated with intimate partner violence and not a low blood pressure.

The nurse is teaching a victim of intimate violence how to create a safety plan. Which should be included when the nurse is assiting the client in devising an escape? Select all that apply. prepare and hide an escape bag map the house for an escape route identify a prearranged place for children to meet recognize signs of the perpetrator losing control configure a list telephone numbers needed in case of emergency

- prepare and hide an escape bag - map the house for an escape route - identify a prearranged place for children to meet - configure a list telephone numbers needed in case of emergency Explanation: One of the most important teaching goals is to help survivors develop a safety plan. When devising the plan include preparing and hiding an escape bag that includes clothes, car and house key, bank account numbers, birth certificate, insurance policies, marriage license, valuable jewelry, telephone numbers, and money. The house should be mapped for an escape route. If children are involved, a prearranged area to meet away from the house should be identified. A safety plan for a child or dependent elder might include safe places to hide and important telephone numbers, including 911 and those of the police and fire departments and other family members and friends. Recognizing signs of the perpetrator losing control is the first step of the plan which helps the victim recognize the signs of danger.

The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply. putting the client down calling the client names making all the decisions making the client feel guilty limiting contact with others

- putting the client down - calling the client names - making the client feel guilty Explanation: Behaviors that suggest that someone is experiencing emotional abuse include putting the person down, name-calling, and making the person feel guilty. Making all the decision is a behavior associated with male privilege. Limiting contact with others demonstrates the use of isolation.

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.) the client's father monitors contact with friends feeling social pressure to use alcohol feeling left out of peer group has a family history of alcohol abuse must go straight home after school each day

- the client's father monitors contact with friends - has a family history of alcohol abuse - must go straight home after school each day Explanation: Having contact with friends monitored by the father indicates there is an abuse of power and control in the home. Having to go straight home after school indicates the client is being forced into social isolation. In addition, there is a family history of alcohol abuse. These are all characteristics of violent families. Adolescents commonly report feelings of being left out and experiencing social pressures to experiment with drugs and alcohol. These are not characteristics of violent families.

A nurse is assessing a Haitian client. The caregiver of the client tells the nurse that the client is having an episode of Bouffée delirante. What symptoms would the nurse expect to find in this client? Select all that apply.

-Confusion -Hallucinations -Extreme aggression

The nurse is explaining the importance of expressing anger to a client. What should the nurse mention as the possible physical complications associated with suppressing anger? Select all that apply.

-Coronary artery disease -Ulcers -Migraine headaches

The nurse is caring for a client with depression. The client has an anger episode. What are the possible behaviors expected in this client during and immediately following the episode? Select all that apply.

-Expresses anger verbally. -Feels guilty for inappropriate anger reaction.

The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply

-Give the client plenty of space. -Request the presence of additional staff. -Sit in an open area

The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply.

-Give the client plenty of space. -Sit in an open area -Request the presence of additional staff.

The nurse working in a psychology clinic finds that suppression of anger is more common in women than in men. What is the possible explanation for such a finding?

Women are expected not to express so-called negative feelings like anger.

What percentage of women can expect to be a victim of an ongoing unwanted pursuit from stalking?

12-32%

What percentage of women can expect to be a victim of an ongoing unwanted pursuit from stalking? 5-10% 12-32% 40-48% 50-60%

12-32% Explanation: Women are 12-32% and men 17% who can expect to be victims of ongoing unwanted pursuit.

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what? 70% women and 30% men 70% men and 30% women 50% women and 50% men 90% women and 10% men

70% women and 30% men Explanation: Approximately 70% of victims killed by IPV are women and 30% are men.

A nurse is caring for clients who are psychologically abused. Which clients should the nurse screen for psychological abuse? Select all that apply.

A partner of a client who has destroyed the front door of their home. A client whose partner is monitoring the amount of money spent on food and clothing. A partner of client who does not want the client to spend any time with family or friends. A parent of a client who is threatening to injury the family's pet.

A nurse is working with a client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which would be most important for the nurse to do?

Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client

A nurse is preparing a presentation for an adolescent and young adult community group about stalking. Which group would the nurse identify as having the highest risk of being stalked?

Women, ages 18 to 24 years

A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing?

Crisis

In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?

Crisis

Approximately what percentage of women rape victims are raped by someone they know?

65%

Approximately what percentage of women rape victims are raped by someone they know? 65% 35% 45% 55%

65% Explanation: Approximately two-thirds of women are raped by people they know, including spouses, boyfriends, friends, or acquaintances. Among young women, about 50% of rapes are date rapes.

Approximately what percentage of women rape victims are raped by someone they know? 65% 35% 45% 55%

65% Explanation: Approximately two-thirds of women are raped by people they know, including spouses, boyfriends, friends, or acquaintances. Among young women, about 50% of rapes are date rapes.

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what?

70% women and 30% men

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what? 70% women and 30% men 70% men and 30% women 50% women and 50% men 90% women and 10% men

70% women and 30% men Explanation: Approximately 70% of victims killed by IPV are women and 30% are men.

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply. A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femur A 15-month-old with shortness of breath after peanut ingestion A 3-year-old with a deep finger laceration

A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femur Explanation: Re-occurring urinary tract infections signal the possibility of sexual abuse of the child. The nurse must assess for further signs of abuse both with parents present and without. A fracture of the femur in a 3-month-old is uncommon given the infant's age and level of development. Contrecoup injuries of the brain in a baby should generate suspicion that the baby has been shaken. A 15-month-old with an allergic reaction to a peanut ingestion and a 3-year-old with a deep finger laceration should not signal abuse to the assessor. The problems are commonly seen in the pediatric emergency room.

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.

A 6-year-old is being seen for the 5th time for a urinary tract infection; A baby with contrecoup injuries to the brain; A 3-month-old with a fractured femur

A nurse is aware of the high incidence of intimate partner violence (IPV) and actively seeks opportunities to screen women for IPV. Which female client represents the best opportunity for assessing for IPV?

A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic

A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:

A cognitive intervention.

Which assessment finding can help the nurse differentiate a child experiencing child neglect rather than child abuse?

A young child is admitted to the hospital with hypothermia because the child is inadequately dressed.

A psychiatric-mental health nurse is conducting a program for a women's group. When describing psychological abuse, which information would the nurse address? Select all that apply.

Criticism Insults Public ridicule Isolating a person from family

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply.

Criticizing, Ridiculing, Threatening a victim's dog

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes?

Cyberstalking

Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which component is critical to the success of the plan?

Access to community resources for referral

Which type of elder abuse involves leaving an older adult and no longer providing care for the individual?

Abandonment

Which characteristics are found in violent families? Select all that apply.

Abuse of power and control; Social isolation; Alcohol use disorder

Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which component is critical to the success of the plan? An intimate partner violence (IPV) counselor Access to community resources for referral A quality of life assessment tool Written educational materials

Access to community resources for referral Explanation: Much of the support and treatment that will be needed for women in abusive relationships is needed in the community. Having access to these resources is the most critical aspect to ensuring effective and sustainable support for women in abusive situations. An IPV counselor in the emergency department will only be available for support when there is an acute situation for which the client has come to hospital. Such a component is effective but not a long-term option to support people in abusive relationships. A quality of life assessment tool is effective for assessment, but this is only the initial part of the plan. Written educational materials are important to enhance knowledge for women in abusive situations; however, community support services are needed to ensure follow through and sustainability.

A nurse is working in a psychiatric-mental health facility. The nurse observes a client pacing and punching the wall. Which measure can the nurse take for personal safety?

Avoid being alone with the client.

A nurse is caring for a child who had experienced sexual abuse. Which are expected behaviors of a child who has experienced sexual abuse? Select all that apply.

Avoidance of sexually related content Secretiveness of behaviors Distorted view of sex

When attempting to preserve evidence from a possible rape with no report of oral sex, the female victim should be instructed that which self-care activities are permitted? Brushing her teeth Douching Showering Changing clothes

Brushing her teeth Explanation: To preserve possible evidence, the physical examination should occur before the women has showered, brushed her teeth, douched, changed her clothes, or had anything to drink.If there is no report of oral sex, then rinsing the mouth or drinking fluids can be permitted immediately.

Which sign of escalating behaviors, if displayed by a client, requires immediate intervention?

Banging the head against the wall

A school nurse is aware that a student has requested aspirin three times during the past week because his "back hurts." The nurse has noticed that he often wears long-sleeved sweaters and sweatshirts even in warm weather. The nurse suspects that the student may be the victim of physical abuse. The nurse is preparing to ask the child about his ongoing backache. Which of the following would the nurse anticipate being reported by the child if he was being abused?

Be reluctant to report abuse because of shame or fear of retaliation

Neurobiologic factors are increasingly being explored as an explanation for aggressive behavior. Which is true?

Brain neuroimaging studies show that aggressive behavior is linked to damage of brain structures located in the limbic, frontal, and temporal lobes.

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present?

Bruises, burns, lacerations, missing teeth, and skeletal injuries

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present? Eye, head, and skeletal injuries; swollen glands; and breaks in skin Broken bones and finger joints, bruises, scars, and eye injuries Bruises, burns, lacerations, missing teeth, and skeletal injuries Missing teeth, scars on genitalia, loose bones, broken legs, and burn marks

Bruises, burns, lacerations, missing teeth, and skeletal injuries Explanation: The most common indicators of physical abuse of a child are as follows: (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present? Eye, head, and skeletal injuries; swollen glands; and breaks in skin Broken bones and finger joints, bruises, scars, and eye injuries Bruises, burns, lacerations, missing teeth, and skeletal injuries Missing teeth, scars on genitalia, loose bones, broken legs, and burn marks

Bruises, burns, lacerations, missing teeth, and skeletal injuries Explanation: The most common indicators of physical abuse of a child are as follows: (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.

When attempting to preserve evidence from a possible rape with no report of oral sex, the female victim should be instructed that which self-care activities are permitted?

Brushing her teeth

The nurse is legally obligated to report suspected child abuse to local authorities. Which information is essential?

Child's name, location, age, and suspected perpetrator

Which term is used to describe an activity used to release anger?

Catharsis

During an interview, a client reveals to the nurse, "I was sexually abused as a child." Based on this information, which finding would the nurse most likely anticipate being revealed during the assessment? Select all that apply. Client has difficulty establishing interpersonal relationships Client has a history of substance abuse Client has difficulty establishing a mutually satisfying sexual relationship Client engages in self-harming behaviors Client exhibits antisocial tendencies

Client has difficulty establishing interpersonal relationships Client has a history of substance abuse Client has difficulty establishing a mutually satisfying sexual relationship Client engages in self-harming behaviors Explanation: Losing the ability to trust people is a common characteristic of the adult survivor of childhood sexual abuse. Substance abuse is a common characteristic of the adult survivor of childhood sexual abuse. Other characteristics include having difficulty establishing interpersonal relationships and finding mutually satisfying sexual relationships. Also, survivors may engage in self-harm.

During an interview, a client reveals to the nurse, "I was sexually abused as a child." Based on this information, which finding would the nurse most likely anticipate being revealed during the assessment? Select all that apply.

Client has difficulty establishing interpersonal relationships Client has a history of substance abuse Client has difficulty establishing a mutually satisfying sexual relationship Client engages in self-harming behaviors

When assessing a client's potential for aggression and violence, which would the nurse identify as the most important predictor?

Client's history

A 27-year-old has been brought to the emergency department by emergency medical services following a violent sexual assault that took place in the parking garage of the client's building. Which task would fall most clearly within the scope of practice of a forensic nurse?

Collecting specimens from the client for use as evidence

A 27-year-old has been brought to the emergency department by emergency medical services following a violent sexual assault that took place in the parking garage of the client's building. Which task would fall most clearly within the scope of practice of a forensic nurse? Providing reassurance to the client that the care team and the police will prioritize the client's care Collecting specimens from the client for use as evidence Assisting with diagnostic tests to determine the extent of the client's injuries Asking the client to describe the perpetrator in detail and documenting the client's statement

Collecting specimens from the client for use as evidence Explanation: While a forensic nurse would certainly attempt to reassure a client such as this one, a priority forensic nursing task would be collecting specimens for use as evidence. This would supersede assisting with diagnostics, which falls within the scope of any registered nurse. The police, not a nurse, would be responsible for taking the client's statement.

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes? Jealousy Isolation Harassment Cyberstalking

Cyberstalking Explanation: Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Cyberstalking is the use of the Internet, e-mail, or other telecommunications technology to harass or stalk another person. The nurse should document the conversation in the nurse's notes.

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes? Jealousy Isolation Harassment Cyberstalking

Cyberstalking Explanation: Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Cyberstalking is the use of the Internet, e-mail, or other telecommunications technology to harass or stalk another person. The nurse should document the conversation in the nurse's notes.

Which is the most commonly identified issue preventing people from leaving an abusive relationship? Dependency Emotional immaturity Jealousy Possessiveness

Dependency Explanation: Dependency is the most common trait seen in abused wives who stay with their husbands. Women often cite personal and financial dependency as reasons why they find leaving an abusive relationship extremely difficult.

A client visits the clinic and tells the nurse that no matter how difficult the client's child acts, the client simply cannot express any anger. The nurse should plan to assess the client for symptoms of which mental health condition?

Depression

A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness?

Development of a therapeutic relationship

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse?

Diagnosed with mild dementia

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse? Lives with adult daughter Diagnosed with mild dementia Requires assistance with food preparation Widowed, female

Diagnosed with mild dementia Explanation: While the risk of elder abuse exists in all the options provided, such abuse is more likely when the elder client has chronic mental and/or physical health problems that limit there ability to express their concerns and/or describe their current living conditions.

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse? Lives with adult daughter Diagnosed with mild dementia Requires assistance with food preparation Widowed, female

Diagnosed with mild dementia Explanation: While the risk of elder abuse exists in all the options provided, such abuse is more likely when the elder client has chronic mental and/or physical health problems that limit there ability to express their concerns and/or describe their current living conditions.

While working in a psychiatric-mental health facility, the nurse notices a client pacing back and forth and becoming increasingly agitated. Which is a critical step in communicating with the client to prevent the escalation of aggressive behavior?

Discover the source of the distress.

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply.

Emotional

A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse? Physical Financial Emotional Sexual

Emotional Explanation: A behavioral profile of an emotionally abused child includes stuttering, enuresis, overeating, disciplinary problems, and failure to thrive. The scenario does not refer to physical, financial, or sexual abuse.

A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse? Physical Financial Emotional Sexual

Emotional Explanation: A behavioral profile of an emotionally abused child includes stuttering, enuresis, overeating, disciplinary problems, and failure to thrive. The scenario does not refer to physical, financial, or sexual abuse.

A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse? Physical Financial Emotional Sexual

Emotional Explanation: A behavioral profile of an emotionally abused child includes stuttering, enuresis, overeating, disciplinary problems, and failure to thrive. The scenario does not refer to physical, financial, or sexual abuse.

A nurse is preparing a presentation for a senior center about elder abuse. When describing individuals associated with abusing older adults, which group would the nurse most likely identify? Select all that apply.

Family member Adults Children Spouses

When interviewing an abused child, the nurse must first complete what? Use vocabulary that the child uses Establish a safe environment Understand forensic implications for assessment Use anatomically correct dolls

Establish a safe environment Explanation: First, the nurse must establish a safe and supportive environment in which to conduct the evaluation. Second, the nurse needs to understand the forensic implication of assessment so that the interview format will be acceptable for disclosure in a court hearing. It is also important to use vocabulary that the child uses and to use anatomically correct dolls to obtain information about the abuse, but these are not the priority.

A nurse is gathering information about a health history of a person who has experienced violence. Which are important caring behaviors a nurse should implement during the interview? Select all that apply.

Establish trustworthiness. Maintain a nonjudgmental attitude. Secure open communication.

A nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?

Experience of health problems and health professionals

A nurse is leading an anger management group in the inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment?

Explore what is underlying the client's physical and emotional state

Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why? Nurses can learn from the experiences of clients and thus help prevent becoming victims of assault themselves. The attitudes of individual nurses reflect on the overall profession. Nurses need to be able to sympathize with their clients. Giving back the survivor as much control as possible is important.

Giving back the survivor as much control as possible is important. Explanation: Knowing how to recognize when personal feelings are likely to interfere with optimal care is part of the nurse's professional responsibility. Giving back the survivor as much control possible is important by allowing the client to make decisions about who to call, what to do next, and what the client would like done in relation to the crime. The nurse's role in helping the survivor regain control is an essential part of recovery.

Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why? Nurses can learn from the experiences of clients and thus help prevent becoming victims of assault themselves. The attitudes of individual nurses reflect on the overall profession. Nurses need to be able to sympathize with their clients. Giving back the survivor as much control as possible is important.

Giving back the survivor as much control as possible is important. Explanation: Knowing how to recognize when personal feelings are likely to interfere with optimal care is part of the nurse's professional responsibility. Giving back the survivor as much control possible is important by allowing the client to make decisions about who to call, what to do next, and what the client would like done in relation to the crime. The nurse's role in helping the survivor regain control is an essential part of recovery.

The nurse is preparing a teaching plan for a client who experiences intimate partner violence. Which topics should the nurse include? Select all that apply.

HIV testing sleep hygiene access to shelters nutritional support

The mental health nurse should discuss an emergency plan for leaving abusive situations will when the woman is able to do which of the following? Select all that apply.

Identifies safe places to go Keep emergency money available Makes a spare car key Compile a list of important phone numbers

A frightened young woman calls the emergency department and tearfully tells the nurse, "I've been raped! Please help me!" Before telling the client what to do, the nurse would need to know if

If the client was injured, was in a safe place, and had transportation available

The nurse finds that a client with a history of aggressive behavior is restless, is pacing up and down in the hallway, and has clenched fists. The client also talks in a loud voice. Which intervention would be most appropriate at this point?

Immediately approach the client to engage in communication

A nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff?

Importance of measuring the clients' progress in small steps

Which personality trait is associated with aggressive behavior?

Impulsivity

A nurse is working with a client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which would be most important for the nurse to do? Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence. Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client. Assist the client in finding a new apartment and a new job so to be safe after leaving the current situation. Suggest that the client legally change his or her name and move out of state to be safe from future harm.

Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client. Explanation: Survivors must understand the cycle of violence and the danger of homicide that increases as violence escalates or when the survivor attempts to leave the relationship. Although survivors also need information about resources (e.g., shelters for battered women), legal services, government benefits, and support networks, the nurse first needs to discuss the possibility of the perpetrator's reaction and the possibility of extreme violence leading to death.

Which are forms of psychological abuse? Select all that apply.

Insulting, Humiliating, isolating a person from family

A client comes to the mental health clinic and reports feeling depressed for the last 3 months. The client also admits to having thoughts of suicide. When the nurse inquires about the client's relationships, the client tells the nurse that the client's spouse constantly belittles the client, telling the client often that the client is "stupid and fat." Which problem should the nurse assess for further?

Intimate partner violence

A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following?

Intimidation

Which statement about intimate partner violence (IPV) is accurate?

Knowledge deficits and biases of health care professionals limit its detection.

A client with aggressive behavior shows no psychotic symptoms. Which medication should the nurse expect to be ordered for this client?

Lorazepam

A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute?

Low self-esteem

A nurse is caring for a young adult in the mental health clinic. The client tells the nurse that the client was physically neglected as a child. The nurse should assess the client for symptoms of what?

Major depression

The nurse should consider which as a possible indicator of child neglect? Malnourishment unrelated to illness Helplessness Angry outbursts Hesitance to talk openly

Malnourishment unrelated to illness Explanation: Malnourishment is a possible indicator of neglect. Helplessness, hesitance to talk openly, and anger could be psychological or emotional indicators of abuse.

A group of nursing students is reviewing information about intimate partner violence (IPV). The group demonstrates understanding of this topic when they identify which of the following?

Men may not consider behaviors such as slapping or shoving as abuse.

A nurse is working with a child whose parents have subjected him to neglect and emotional maltreatment, which primarily took the form of unavailability and general disinterest in his welfare. The nurse should expect that a child subjected to this type of maltreatment would experience problems in which of the following?

Multiple intellectual, physical, behavioral, and emotional arenas

A nurse is reading a journal article about anger and violence. Which would the nurse expect to see as being linked to excessive, outwardly directed anger?

Myocardial infarction

An 8-month-old infant has been brought to the emergency department unresponsive by the infant's teenage parent and the care team suspects shaken baby syndrome. When providing care for this infant, the nurse should prioritize which assessment?

Neurological assessment

When determining a client's potential for aggression and violence prior to engaging in a detailed psychosocial assessment, which would be most important for the nurse to do?

Obtain a thorough client history

A nurse's response to aggressive behavior on the unit is influenced by the which ability of the nurse?

Own awareness and reaction to aggression

A nurse must assess a client's thought process and content to identify risk for aggression. The assessment of the client's thought process and content would allow the nurse to identify what?

Perceptions and delusions

In which phase of the aggression cycle is the client removed from restraint or seclusion as soon as he or she meets the behavioral criteria?

Postcrisis

The nurse is assessing a group of clients on an inpatient psychiatric unit. The nurse determines that a client most likely to be violent has what?

Previous episodes of rage

Which statement requires additional education regarding the truth about rape?

Rape is a crime of passion.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first?

Recognizing the signs of danger

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first? Devising an escape route Recognizing the signs of danger Identifying a safe place to hide Identifying a signal to indicate it is safe to leave

Recognizing the signs of danger Explanation: One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first? Devising an escape route Recognizing the signs of danger Identifying a safe place to hide Identifying a signal to indicate it is safe to leave

Recognizing the signs of danger Explanation: One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.

During which phase of the aggression cycle does the client regain physical and emotional control?

Recovery

During which phase of the aggression cycle does the staff usually have a debriefing session?

Recovery

Which provides the most acceptable example of neglect according to the definition of the term?

Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls

Which provides the most acceptable example of neglect according to the definition of the term? Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls When an adult does not intervene when a 10-year-old child is being bullied by older peers Disciplining a 6-year-old child for "sassing" by putting tape on the child's mouth Correcting a child for copying homework in front of the entire class

Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls Explanation: Neglect is an act of omission and refers to a parent's or other person's failure to meet a dependent's basic needs, such as providing appropriate emotional care. Telling a 3-year-old to stop crying like a baby when the child stumbles and falls is an example of neglect.

Which provides the most acceptable example of neglect according to the definition of the term? Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls When an adult does not intervene when a 10-year-old child is being bullied by older peers Disciplining a 6-year-old child for "sassing" by putting tape on the child's mouth Correcting a child for copying homework in front of the entire class

Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls Explanation: Neglect is an act of omission and refers to a parent's or other person's failure to meet a dependent's basic needs, such as providing appropriate emotional care. Telling a 3-year-old to stop crying like a baby when the child stumbles and falls is an example of neglect.

The nurse has been working on anger management with the client. The client yells during dinner, "Give me that salt shaker!" What is the best nursing intervention at this time?

Remind the client about communication skills discussed earlier

A nurse is caring for a client who arrived at the emergency room with injuries following a physical assault with a baseball bat. The client tells you that their significant other is responsible for the injuries. Place the following nursing actions in order from the highest importance to the lowest importance. All options must be used. Remove the significant other from the room with the client. Conduct an assessment of the client. Notify the physician of the client's injuries and situation. Notify the police of the assault. Call a meeting of the interdisciplinary team

Remove the significant other from the room with the client. Conduct an assessment of the client. Notify the physician of the client's injuries and situation. Notify the police of the assault. Call a meeting of the interdisciplinary team Explanation: The priority in this situation is the safety of the client. Therefore, the significant other should be removed from the room with the client to prevent further injury. The nurse should complete a full assessment of the client and then notify the physician of the assessment findings and situation. In cases of assault the police will need to be notified because this is a criminal act. The final intervention should be calling a meeting of the interdisciplinary team to evaluate the clients situation and identify all available resources.

A nurse is caring for a client who arrived at the emergency room with injuries following a physical assault with a baseball bat. The client tells you that their significant other is responsible for the injuries. Place the following nursing actions in order from the highest importance to the lowest importance. All options must be used.

Remove the significant other from the room with the client. Conduct an assessment of the client. Notify the physician of the client's injuries and situation. Notify the police of the assault. Call a meeting of the interdisciplinary team

During the nurse's assessment of a new client on a medical unit, the client confides in the nurse that the client's spouse often "slaps me around" after the client has been drinking. What action should the nurse take in response to this statement?

Report the client's statement promptly to the appropriate authorities.

During the nurse's assessment of a new client on a medical unit, the client confides in the nurse that the client's spouse often "slaps me around" after the client has been drinking. What action should the nurse take in response to this statement? Ask the client to write down descriptions of these instances and make these documents part of the client's medical record. Discuss with the client the possible triggers that set off the spouse's behavior. Report the client's statement promptly to the appropriate authorities. Elicit further detail from the client to determine the validity of the accusation.

Report the client's statement promptly to the appropriate authorities. Explanation: The nurse's responsibility in cases of suspected abuse is to report the allegations. It is not the nurse's responsibility to determine validity, encourage a written statement, or counsel the client on the dynamics of the abuse.

Which type of rapist derives erotic gratification from the victim's suffering?

Sadistic rapist

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what?

Same frequency as in heterosexual couples

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what? Twice as often as in heterosexual couples Same frequency as in heterosexual couples Half as frequent as in heterosexual couples Three times more frequent as in heterosexual couples

Same frequency as in heterosexual couples Explanation: Intimate partner violence in same-sex couples occurs with at least the same frequency as in heterosexual relationships, but people with same-sex partners may not be afforded the same support.

A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter?

Serotonin

The nurse is caring for a client hospitalized in an inpatient psychiatric setting for a history of violent behaviors and delusions. The nurse should instruct the client's family that aggression has been linked to low levels of which bodily chemical?

Serotonin

In a toddler, which injury is most likely the result of child abuse?

Several small, circular burns on the child's back

An older adult client has been attending a local day program for the elderly. The nurse who facilitates the program notices the client has multiple bruises on the arms, has scrapes to the hands and face, and is socially withdrawn. A referral to the client's family physician confirms the client has genital herpes. Which type of elder abuse should the nurse suspect?

Sexual abuse

A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition? Shaken baby syndrome Munchausen's syndrome by proxy Ineffective supervision Child neglect

Shaken baby syndrome Explanation: Despite its name, shaken baby syndrome has been documented in children up to 5 years of age. The physical findings usually include bruising from being grabbed firmly along with major head injury, such as subdural hematoma or cerebral edema. Nonfatal consequences include blindness due to retinal hemorrhage.

A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition? Shaken baby syndrome Munchausen's syndrome by proxy Ineffective supervision Child neglect

Shaken baby syndrome Explanation: Despite its name, shaken baby syndrome has been documented in children up to 5 years of age. The physical findings usually include bruising from being grabbed firmly along with major head injury, such as subdural hematoma or cerebral edema. Nonfatal consequences include blindness due to retinal hemorrhage.

Aggression control can be measured by the nurse's observation of a client's ability to do what?

Show an increased tolerance for frustration

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.)

the client's father monitors contact with friends; has a family history of alcohol abuse; must go straight home after school each day

Which situation is likely to have the least influence on the a child's ability to develop socially appropriate behaviors?

Spending time in foster care

The majority of perpetrators of elder abuse include which population?

Spouses

The majority of perpetrators of elder abuse include which population? Spouses Adult children Siblings Grandchildren

Spouses Explanation: Most cases of elder abuse occur when one older spouse is taking care of another.

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect?

Stalking

Which is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency?

Stalking

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect? Intimate partner violence Stalking Sexual assault Neglect

Stalking Explanation: Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency (CDC, 2016b). Stalking is a crime of intimidation. Stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Stalking may include such behaviors as following someone, showing up at the person's home or workplace, vandalizing property, or sending unwanted gifts. Intimate partner violence is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. In this case, the relationship is spousal, and 15-25% of pregnant women experience violence during pregnancy. Sexual assault is the act of forcing unwanted sexual activity on a person. In this case, the nurse should first suspect intimate partner violence and can further inquire if unwanted sexual activity is also a feature of the client's situation. Neglect is considered in the context of child abuse.

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect? Intimate partner violence Stalking Sexual assault Neglect

Stalking Explanation: Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency (CDC, 2016b). Stalking is a crime of intimidation. Stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Stalking may include such behaviors as following someone, showing up at the person's home or workplace, vandalizing property, or sending unwanted gifts. Intimate partner violence is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. In this case, the relationship is spousal, and 15-25% of pregnant women experience violence during pregnancy. Sexual assault is the act of forcing unwanted sexual activity on a person. In this case, the nurse should first suspect intimate partner violence and can further inquire if unwanted sexual activity is also a feature of the client's situation. Neglect is considered in the context of child abuse.

A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action?

Take the client to the gym for exercise

The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "He makes me so mad when he spends all his weekend time with his friends instead of us. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which intervention after hearing the wife's remarks?

Teach the client to make "I" statements.

Which is not a risk factor for child sexual abuse?

The child is aged 10 years or younger.

Which feature would most likely predispose an adult to engage in family violence?

The adult was physically abused as a child

Which feature would most likely predispose an adult to engage in family violence? The adult was physically abused as a child The adult has been experiencing financial problems The adult experiences chronic mild depression The adult is used to being in control

The adult was physically abused as a child Explanation: The tendency for adults to raise their children in the same way that they were raised perpetuates the cycle of family violence. Adults who were victims of abuse as children frequently abuse their own children.

The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply. The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection There are frequent ear infections

The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection Explanation: The nurse's suspicion that a child has been sexually abused is supported when the assessment data includes a bruised anal area, itching reported by the child, an edematous vulva, and a urinary infection. Ear infections are common among children.

The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply.

The anal area is bruised; The child reports "itching down there"; The vulva appears edematous; The urinalysis reports a bacterial infection

The psychiatric nurse recognizes that a male rape victim is less likely to report the crime due to which reason?

The belief that his masculinity will be in question

Which is not a risk factor for child sexual abuse? The child is aged 10 years or younger. The child suffers from developmental delays. The child lives in a home where substance abuse occurs. The child has primary caretaker who is mentally ill.

The child is aged 10 years or younger. Explanation: Children at high risk for sexual abuse include those who • Are aged 3 years or younger • Suffer from a developmental delay • Live in a home where substance abuse occurs • Have adolescent parents or a single parent • Are in foster care • Have primary caretakers who were sexually abused themselves • Have primary caretakers who are mentally ill or have a developmental delay

A nurse is assessing a Korean client. The caregiver of the client tells the nurse that the client had been diagnosed with Hwa-Byung by their local health care provider. What should the nurse interpret from this?

The client had health-related issues due to suppression of anger.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply.

The client is embarrassed of the assault.; They have a fear of being; blamed for the incident; The perpetrator may use coercion or threats to control the victim.

A client who has been victimized repeatedly by a spouse is angry and verbally lashing out on the nurse. Based on the client's behavior, which technique would the nurse use with this client?

use "I feel" statements

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply. The client is physically dependent on the client's son since losing mobility. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." The client and client's child are recent immigrants to the United States. The client self-describes and describes the client's child as "not well-off, but not terribly poor either."

The client is physically dependent on the client's son since losing mobility. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." Explanation: Physical and financial dependence and personality conflicts with caregivers and children are known to contribute to elder abuse. Low socioeconomic status and recent immigration are not identified as causative factors.

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply.

The client is physically dependent on the client's son since losing mobility.; The client has no income or savings of the client's own.; The client's son describes the client as "needy, helpless, and pathetic."

A client comes to the clinic for an evaluation. The nurse assesses the client and suspects that the client is a victim of abuse. Which finding would support the nurse's suspicion? Select all that apply.

The client is vague about the injuries on the body. The client minimizes the severity of the injuries. The client has a history of frequent visits to the emergency department for injuries.

A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met?

The client uses adaptive coping to manage anger impulses.

A nurse is screening a new client for intimate partner violence (IPV). What aspect of this woman's current circumstances is the most significant risk factor?

The client's family lives on less than $1,000 per month.

Which would not increase the likelihood that an older adult will incur physical abuse?

The older adult is independent with activities of daily living.

Which would not increase the likelihood that an older adult will incur physical abuse? The older adult is independent with activities of daily living. The older adult has difficulty with mobility and can become confused. The older adult lives with a son who receives financial aid. An older adult reports frequent multiple bruises that are related to falls.

The older adult is independent with activities of daily living. Explanation: The correct option indicates that the older adult enjoys independence, an attribute that is not commonly seen in those older adults who experience physical abuse. Common factors that predispose older adult clients to physical abuse include having chronic medical or mental health conditions, living with a familial caregiver who is a male and has financial problems, and the reluctance to report abuse despite the presence of signs such as multiple bruises.

Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence?

They are at increased risk for being abused.

Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence? They are at increased risk for being abused. They have higher rates of schizophrenia. It has little impact on child functioning. Female children are more likely to experience depression.

They are at increased risk for being abused. Explanation: Children being raised in a home where they have witnessed intimate partner violence demonstrate higher levels of depression and lower levels of self-esteem; these effects are pronounced in boys especially. Children of battered women are at an increased risk for abuse. Exposure to intimate partner violence adversely affects a range of child functioning.

Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response?

Triggering

A nurse is giving a talk about child abuse to a local community group. When discussing risk factors for child abusers, which would the nurse identify as the most likely profile of the perpetrator of fatal child abuse?

Unemployed young woman who dropped out of high school

The nurse provides care to individuals who have been sexually assaulted during their childhood. Which characteristic is most commonly noted by the nurse during an assessment of such clients?

Unusually aggressive

Which three elements are necessary to legally define rape of a male, female, or mixed gendered person? Use of force; vaginal, oral, or anal penetration; nonconsent of victim Use of force, consent of victim, oral penetration Use of gun or weapon, nonconsent of victim, victim unaware of assault Nonconsent of victim, bruising or swelling of perineum, lack of duress

Use of force; vaginal, oral, or anal penetration; non-consent of victim Explanation: Three essential elements are necessary to legally define rape of a man or woman: • Use of force, threat, intimidation, or duress • Vaginal, oral, or anal penetration • Non-consent by the victim

Which is an inaccurate picture of the cycle of abuse that occurs over time?

Violent episodes are less frequent

The nurse is planning a community education session on elder abuse awareness. Which points should the nurse be sure to include? (Select all that apply.)

Withholding money for necessities is a form of abuse Not helping you get medical attention you need is a form of abuse It is abuse if you feel forced to have sex It is abuse if your caregiver holds your arm too tight

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement?

abandonment

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement? neglect physical emotional abandonment

abandonment Explanation: Although abandonment can cause neglect and lead to physical and emotional abuse, abandonment is the primary type of abuse that this person is experiencing. The older person is calling for help because the caregiver has not been present for days. Neglect is the failure to meet basic needs of shelter and food. Physical abuse is causing injury by hitting, kicking, or pushing. Emotional abuse is injuring the person's self-worth and emotional well-being.

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement? neglect physical emotional abandonment

abandonment Explanation: Although abandonment can cause neglect and lead to physical and emotional abuse, abandonment is the primary type of abuse that this person is experiencing. The older person is calling for help because the caregiver has not been present for days. Neglect is the failure to meet basic needs of shelter and food. Physical abuse is causing injury by hitting, kicking, or pushing. Emotional abuse is injuring the person's self-worth and emotional well-being.

A young adult client female is assessed after being raped. The client reports being tied up and beaten while the perpetrator forced sexual intercourse. She recalls the perpetrator saying, "I will make you pay." What most accurately describes this category of rapist?

anger retaliation

A young adult client female is assessed after being raped. The client reports being tied up and beaten while the perpetrator forced sexual intercourse. She recalls the perpetrator saying, "I will make you pay." What most accurately describes this category of rapist? power assertive anger retaliation power reassurance anger excitement

anger retaliation Explanation: In this case, the most accurate description of this rapist is anger retaliation. In this category, the perpetrator wants to punish the victim and often causes substantial injury. The power assertive rapist desires to dominate and control the victim and may repeat with the same victim. The power reassurance rapist commits rape when the opportunity presents itself, such as when another crime is being committed. An anger excitement rapist acts out fantasies and can be strategic in carrying out the crime, for example, carries a rape kit.

The nurse suspects that a client is a victim of intimate partner violence. What should the nurse consider when caring for this client? Select all that apply.

availability of support; support can be accessed safely

The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment? child crying and appearing sad child exhibiting reluctance to play with other children parent encouraging the child to help with household chores parent limiting the amount of time the child watches television

child crying and appearing sad Explanation: Children who witness intimate partner violence are often overlooked as abuse victims. Witnessing violence puts children at risk for developing depression which can be demonstrated by crying and appearing sad. Reluctance to play with other children could have many causes however does not indicate intimate partner violence in the home. Helping with household chores and limiting television time are not indications that the child is exposed to intimate partner violence in the home.

The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment? child crying and appearing sad child exhibiting reluctance to play with other children parent encouraging the child to help with household chores parent limiting the amount of time the child watches television

child crying and appearing sad Explanation: Children who witness intimate partner violence are often overlooked as abuse victims. Witnessing violence puts children at risk for developing depression which can be demonstrated by crying and appearing sad. Reluctance to play with other children could have many causes however does not indicate intimate partner violence in the home. Helping with household chores and limiting television time are not indications that the child is exposed to intimate partner violence in the home.

The nurse plans to assess a pregnant client for intimate partner violence. Which finding caused the nurse to complete this additional assessment? Select all that apply.

chronic anemia smoking cigarettes ingestion of alcohol low maternal weight gain

The nurse is assessing an adolescent in a psychiatric facility. The parent tells the nurse that the adolescent has intense sporadic anger episodes. The adolescent becomes angry for petty reasons and starts throwing objects at home. The adolescent also feels guilty and repents for the actions. Based on this history, the nurse would expect the client to be diagnosed with:

intermittent explosive disorder.

The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child

is acting out.

The nurse is assessing a client and suspects that the client is a victim of intimate partner violence. The client is experiencing palpatations. What additional findings should the nurse assess the client for related to intimate partner violence? Select all that apply.

missing teeth inability to fully extend the right leg wearing clothing inappropriate for the weather variety of wounds in different stages of healing

The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse?

neglect

The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse? physical sexual neglect psychological

neglect Explanation: Neglect, in this case, is the malicious withholding of a physical necessity for this child's well-being. For this child, the neglect is intended to be punitive for bed wetting. The nurse would need to investigate further and take the necessary action in reporting this as abuse. Sexual abuse refers to sexual acts performed by an adult on a child under the age of 18. In this case, the evidence does not support that the child is being sexually abused. Physical abuse refers to a deliberate physical assault by an adult on the child such as burning, biting, poking, or twisting a limb. Psychological abuse refers to verbal assaults such as blaming, screaming, name-calling, and using sarcasm. The child has not reported that this is occurring, therefore, this is most likely a situation in which the form of abuse is neglect.

When assessing a 6-year-old child believed to be a victim of emotional abuse, the possibility is supported when the child is ...

observed to be anxious and rejecting adult attention.

When assessing a 6-year-old child believed to be a victim of emotional abuse, the possibility is supported when the child is ... observed to be anxious and rejecting adult attention. showing signs of developmental delays. attending day care 5 days a week. parented by a single parent.

observed to be anxious and rejecting adult attention. Explanation: While anxiety can be a sign of many different problems, an anxious child who rejects the attention of an adult may raise a red flag encouraging the nurse to assess further and possibly making a report. Developmental delays are not necessarily an indicator of emotional abuse, nor is attending day care on a regular basis. Being raised by a single parent is also not necessarily an indicator of emotional abuse.

When assessing a 6-year-old child believed to be a victim of emotional abuse, the possibility is supported when the child is ... observed to be anxious and rejecting adult attention. showing signs of developmental delays. attending day care 5 days a week. parented by a single parent.

observed to be anxious and rejecting adult attention. Explanation: While anxiety can be a sign of many different problems, an anxious child who rejects the attention of an adult may raise a red flag encouraging the nurse to assess further and possibly making a report. Developmental delays are not necessarily an indicator of emotional abuse, nor is attending day care on a regular basis. Being raised by a single parent is also not necessarily an indicator of emotional abuse.

The nurse completes screening a client and determines that abuse is occurring in the home. Which should the nurse do before completing a physical assessment?

offer the client the use of the telephone

A school health nurse is seeing an 11-year-old child who is refusing to attend school for the past 3 weeks. On assessment, the child describes a recent school experience where the child has been deliberately isolated from social groups. The child tells the nurse this began after an argument with their "best friend." The child is describing:

ostracism

A school health nurse is seeing an 11-year-old child who is refusing to attend school for the past 3 weeks. On assessment, the child describes a recent school experience where the child has been deliberately isolated from social groups. The child tells the nurse this began after an argument with their "best friend." The child is describing: ostracism terrorism neglect child abuse

ostracism Explanation: In this case, the child is experiencing ostracism. Ostracism refers to ignoring or excluding a target individual and is a damaging form of bullying. The child's adjustment is clearly being threatened as the child is no longer able to attend school. Terrorism refers to community violence that takes place on a larger scale. Neglect refers to the malicious or ignorant withholding meeting a child's needs for their well-being. This is the abuse of a child by a parent or primary caregiver. Child abuse refers to the various forms of abuse rendered on a child by an adult in the role of caregiver.

The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply.

putting the client down calling the client names making the client feel guilty

The nurse is assessing a victim who is brought into the hospital after being found badly beaten and raped by an unknown person. Which healthcare professional should the nurse contact to collect evidence of the assault? healthcare provider on call client's primary care provider sexual assault nurse examiner charge nurse of the emergency room

sexual assault nurse examiner Explanation: Examination for sexual abuse may require referral to a trained registered nurse in sexual assault, known as a SANE (sexual assault nurse examiner). This person is specially trained in protecting evidence. The healthcare provider on call and the client's primary care provider are not the appropriate professionals to contact to collect evidence from a rape. The charge nurse would not be appropriate either.

A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition?

shaken baby syndrome

While assessing for intimate partner violence, the nurse learns that a client has not seen immediate family members for several years because the visits would upset the client's spouse. On which potential issue should the nurse focus with this client?

social isolation

The nurse is caring for a client who is a victim of intimate violence. The client has pressed charges and the perpetrator is involuntarily remanded to a treatment center for 5 years. The client asks the nurse about the requirements of the treatment center that will help prevent ongoing substance abuse. Which of the following required actions does the nurse include in the correct response?

submit to random drug testing

The nurse is caring for a client who is a victim of intimate violence. The client has pressed charges and the perpetrator is involuntarily remanded to a treatment center for 5 years. The client asks the nurse about the requirements of the treatment center that will help prevent ongoing substance abuse. Which of the following required actions does the nurse include in the correct response? attend group therapy sessions submit to random drug testing spend time in solitary confinement attend Alcoholics Anonymous meetings

submit to random drug testing Explanation: Intervention programs may require abusers to undergo substance abuse treatment concurrently, so clients are required to remain sober and to submit to random drug testing. Treatment centers will use a variety of approaches however none are specifically identified such as group therapy, solitary confinement, or attending Alcoholics Anonymous meetings.

While talking with a client who is suspected of being a victim of intimate partner violence, the nurse observes that the client receives repeated text messages. The client states that the messages from the spouse, who is demanding to know where the client is, with whom, and when the client plans to return home. Which phase within the cycle of violence does the nurse assess that the client is experiencing?

tension building

Which child has the greatest risk for being the target of bullying at school?

the child who wears hearing aids

Which child has the greatest risk for being the target of bullying at school? the child who just transferred to the school the child who wears hearing aids the child who recently immigrated to America the child who is short for his or her age

the child who wears hearing aids Explanation: Children with special physical health-care needs are bullied more often, and children with a chronic emotional, behavioral, or developmental problem are more likely to be a victim of bullying. While any child may be a target for bullying, none on the other children have the obvious risk factor that a special needs child brings about.

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.) the client's father monitors contact with friends feeling social pressure to use alcohol feeling left out of peer group has a family history of alcohol abuse must go straight home after school each day

the client's father monitors contact with friends has a family history of alcohol abuse must go straight home after school each day Explanation: Having contact with friends monitored by the father indicates there is an abuse of power and control in the home. Having to go straight home after school indicates the client is being forced into social isolation. In addition, there is a family history of alcohol abuse. These are all characteristics of violent families. Adolescents commonly report feelings of being left out and experiencing social pressures to experiment with drugs and alcohol. These are not characteristics of violent families.

A client who has been victimized repeatedly by a spouse is angry and verbally lashing out on the nurse. Based on the client's behavior, which technique would the nurse use with this client? use "I feel" statements suggest reenacting the abuse instruct in relaxation techniques provide stories about survivors of abuse

use "I feel" statements Explanation: Anger and rage are part of the healing process for survivors and should be expected. Anger management techniques include appropriately recognizing and labeling anger and expressing it assertively. Assertive ways of expressing anger include owning the feeling by using "I feel" statements. Reenacting the abuse, relaxation techniques, and reading stories about survivors are appropriate techniques to help a child who is a victim of abuse.