Chapter 28 Child, Older Adult, and Intimate Partner Violence
What are the three levels of help that can be provided to the abusive family to build a healthy therapeutic environment? Select all that apply. 1 Providing family therapy 2 Helping to prosecute the perpetrator 3 Discouraging social interactions 4 Arranging visits by a nurse 5 Providing economic support
1 Providing family therapy 4 Arranging visits by a nurse 5 Providing economic support
When interviewing an adult victim of abuse, the nurse's best approach is to be A. confrontational and assertive. B. gentle and direct. C. direct and professional. D. sympathetic and outraged.
C. direct and professional.
A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This situation can be an example of A. neglect. B. physical maltreatment. C. emotional violence. D. harsh parenting.
C. emotional violence.
A community health nurse starts working with the family of a victim of domestic abuse. What strategies for primary prevention are helpful in this case? Select all that apply. 1 Reducing stress in the family 2 Increasing the amount of social support 3 Increasing the use of coping skills 4 Arranging a legal advocacy program 5 Decreasing family interactions
1 Reducing stress in the family 2 Increasing the amount of social support 3 Increasing the use of coping skills
Abuse comes in which forms? Select all that apply. 1 Economic 2 Emotional 3 Sexual 4 Physical 5 Intellectual
1 Economic 2 Emotional 3 Sexual 4 Physical
A nurse is assessing an infant and concludes that he or she has shaken baby syndrome. Which symptoms has the nurse found in the infant? Select all that apply 1 Retinal hemorrhages 2 Ear infection 3 Bulging fontanels 4 Respiratory problems 5 Malnourishment
1 Retinal hemorrhages 3 Bulging fontanels 4 Respiratory problems
An elderly woman who has been abused by her caregiver daughter tells the nurse, "You don't have to worry about me. My daughter cried and apologized. She promised me she will never hit me again." The nurse can assess that this is the stage in the cycle of violence known as A. tension building. B. acute battering. C. honeymoon. D. escalation.
C. honeymoon.
The nurse is preparing a safety plan for a victim of family violence. How does a safety plan help the victim? 1 The victim can identify signs of occurrence of violence and leave. 2 The victim can call law enforcement to intervene in a crisis situation. 3 The victim can call the nurse if there is any suicidal ideation. 4 The victim can stay calm and relaxed during an episode of violence.
1 The victim can identify signs of occurrence of violence and leave.
A nurse is teaching patients in a primary health care center how to escape and avoid being a victim of abuse by their partners. Which action of a participant indicates effective teaching? Select all that apply. 1 Identifying the signs of escalation of violence 2 Staying with the abuser to make him or her calm and relaxed 3 Showing extreme trust of his or her partner 4 Packing a bag with money and birth certificates 5 Leaving the place immediately if there are signs of violence
1 Identifying the signs of escalation of violence 4 Packing a bag with money and birth certificates 5 Leaving the place immediately if there are signs of violence
What findings are important for the nurse to document at the initial assessment of a case of domestic abuse? Select all that apply. 1 Physical evidence of sexual abuse, whenever possible 2 Body map to describe the injuries along with explanations 3 Verbatim statements of who caused the injury and when 4 Discussion with other interviewers and their comments 5 The reactions of the nurse on the severity of the event
1 Physical evidence of sexual abuse, whenever possible 2 Body map to describe the injuries along with explanations 3 Verbatim statements of who caused the injury and when
A 79-year-old patient in the emergency department is 5'6", weighs 93 pounds, and is wearing old, dirty clothes that have holes. The patient is diagnosed with pneumonia. Which comment by this patient suggests a significant risk for abuse? 1 "Our family is poor, so my daughter gets my monthly retirement and Social Security checks." 2 "Volunteers from our community food bank have been bringing my groceries for the last few months." 3 "I've lived alone all my life. I have my own ways of doing things and I don't like others to interfere." 4 "I've had a bad cold for months. My daughter made chicken noodle soup for me, but I kept getting worse."
1 "Our family is poor, so my daughter gets my monthly retirement and Social Security checks."
Which principle will guide the nursing interview that is focused on identifying possible family-centered violence? Select all that apply. 1 A person who feels judged or accused of wrongdoing is likely to become defensive. 2 Stop the telling of the abuse whenever clarification is needed. 3 Focus upon identifying problems and acceptable ways of solving them. 4 Establishing a trustful rapport is the initial nursing intervention. 5 Tension is best minimized by asking the sensitive questions first.
1 A person who feels judged or accused of wrongdoing is likely to become defensive. 3 Focus upon identifying problems and acceptable ways of solving them. 4 Establishing a trustful rapport is the initial nursing intervention.
A victim of domestic abuse is being treated for low selfesteem. What are the expected treatment outcomes? Select all that apply. 1 Describes positive level of confidence 2 Has neglectful behaviors towards the abuser 3 Expects positive responses from others 4 Conveys a desire to kill the perpetrator 5 Maintains eye contact and erect posture
1 Describes positive level of confidence 3 Expects positive responses from others 5 Maintains eye contact and erect posture
A married couple that has had a violent marriage decides to participate in family or marital therapy. What are the expected outcomes of family psychotherapy for the perpetrator? 1 To recognize destructive patterns of behavior and learn alternative responses 2 To become temperamental and handle a crisis situation impulsively 3 To express anger and disappointment to the members of the family 4 To develop reclusive behavior and isolate one's self from others in the family
1 To recognize destructive patterns of behavior and learn alternative responses
During a health screen in a boarding school, the nurse finds that the older children have been physically abused. Which signs and symptoms does the nurse find in the children? 1 The children give appropriate reasons for their injuries. 2 The children have nonspecific bruising on their hands. 3 The children tend to maintain stable eye contact with the nurse. 4 The children hesitate to interact with the nurse.
4 The children hesitate to interact with the nurse.
The victim of abuse can expect the abuse to worsen when A. the perpetrator feels he is in complete control. B. the perpetrator is feeling remorseful for being abusive. C. the victim moves toward independence from the abuser. D. the victim submits to the domination of the perpetrator.
C. the victim moves toward independence from the abuser
A nursing intervention directed at the psychological needs of an abused woman is to 1 Encourage the patient to immediately leave the abuser 2 Affirm that the patient did not deserve or cause the abuse 3 Provide a referral to social services for economic problems 4 Facilitate contact with law enforcement to take legal action
2 Affirm that the patient did not deserve or cause the abuse
An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically.
ANS: A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.
In the tertiary prevention method, what measures are taken to assist the survivors of abuse in the healing process? Select all that apply. 1 Support the survivors to remain in social isolation and avoid interaction. 2 Counsel the individuals and families for healing and rehabilitation. 3 Counsel the survivors to hate and stay away from the perpetrator. 4 Assist the survivors of violence to achieve safety, health, and well-being. 5 Assist in dealing with the legal proceedings against the perpetrator.
2 Counsel the individuals and families for healing and rehabilitation. 4 Assist the survivors of violence to achieve safety, health, and well-being. 5 Assist in dealing with the legal proceedings against the perpetrator.
A nurse assesses a victim of intimate partner violence and observes bruises, lacerations, scars, burns, and wounds in various phases of healing. The patient says, "He's going to kill me next time if I don't do something." Which nursing diagnosis has the highest priority? 1 Pain 2 Powerlessness 3 Risk for infection 4 Impaired skin integrity
2 Powerlessness
The nurse is caring for a victim of elder abuse. What are the issues addressed in abuse protection support for older adults? Select all that apply. 1 Education on preventing family interaction to reduce abuse 2 Prevention of infliction of physical, sexual, or emotional harm 3 Identification of high-risk, dependent elder relationships 4 Education on maintaining older adult's power in relationships 5 Prevention of neglect of the older adult's basic necessities of life
2 Prevention of infliction of physical, sexual, or emotional harm 3 Identification of high-risk, dependent elder relationships 5 Prevention of neglect of the older adult's basic necessities of life
A patient prepares for discharge from the emergency department after treatment for injuries associated with intimate partner violence. The patient plans to return home. Which action by the nurse has priority? 1 Refer the patient for pastoral counseling. 2 Provide the patient with contact information for the local shelter. 3 Encourage the patient to file criminal charges against the perpetrator. 4 Tell the patient, "I have documented your injuries and treatment thoroughly."
2 Provide the patient with contact information for the local shelter.
A one-year-old child has respiratory problems and is vomiting. Examinations show the child has bulging fontanels and a retinal hemorrhage. What should the nurse suspect? 1 Injuries due to a fall 2 Shaken baby syndrome 3 Posttraumatic stress disorder 4 Upper respiratory illness
2 Shaken baby syndrome
A person comes to the health care facility with a bleeding head injury and some bruises to both hands. What signs would indicate this person is a victim of domestic abuse? Select all that apply. 1 The patient exaggerates the seriousness of the injury. 2 The patient has weak and nervous behavior. 3 The patient's explanation is inconsistent. 4 The patient gives hesitant explanations. 5 The patient makes direct eye contact.
2 The patient has weak and nervous behavior. 3 The patient's explanation is inconsistent. 4 The patient gives hesitant explanations.
A nurse visits an old age home to assess the presence of abuse. Which response of a patient would indicate that he or she has been neglected? 1 "I spend my time by interacting with my neighbors; we pour our hearts out." 2 "I am grateful for this wheelchair; without it I would be dependent on my children to move." 3 "I am unable to administer the medications; the medication bottles are not clearly marked." 4 "I sit near this window in the morning; the warm sunrays and cool breeze lift my mood."
3 "I am unable to administer the medications; the medication bottles are not clearly marked."
Which of the following is a likely behavior for a woman attempting to escape a chronically abusive relationship? A. Relying on alcohol to escape the emotional pain of abuse B. Adapting an aggressive attitude toward her abuser to scare him C. Considering ways to commit suicide D. Threatening to call the police if she is abused again
C. Considering ways to commit suicide
When a woman reports an injury after being abused by her husband, the nurse listens to her attentively and asks her necessary questions to understand the history. What should the nurse do next to help this woman? 1 Provide a counseling session for the woman and send her home. 2 Advise the woman that she is "in trouble" and needs to find a shelter. 3 Assess safety and help explore alternatives to reduce dangers. 4 Display anger and
3 Assess safety and help explore alternatives to reduce dangers.
An emergency department nurse whispers to a colleague, "That woman is back again. She does the same thing repeatedly. He beats her up, she comes to the emergency department, we stitch her up, they make up, and then he beats her again. Why does she let it keep happening?" What is the colleague's best action? 1 Determine whether the nurse is a victim of abuse. 2 Suggest the nurse consider transfer to a different hospital unit. 3 Encourage the nurse to discuss this reaction with the supervisor. 4 Recommend that the nurse share these sentiments with the patient.
3 Encourage the nurse to discuss this reaction with the supervisor.
A school nurse assesses multiple bruises and welts in odd shapes on a child's back. Lately, this child has been frequently tardy and has had episodes of aggressive behavior in school. Identify the best initial outcome. The child will: 1 Attend school on time 2 Acknowledge abuse by caregivers 3 Form a trusting relationship with the nurse 4 Refrain from aggressive behavior with others
3 Form a trusting relationship with the nurse
A patient who was physically abused is diagnosed with hopelessness related to social isolation, fear related to perceived physical threat, and risk of infection related to injuries. What outcomes indicate effective treatment? 1 Has minor pain in the joints 2 Needs assistance to set goals 3 Has effective wound healing 4 Has nightmares quite often
3 Has effective wound healing
A woman reports being in an abusive relationship with her husband. What drives a man to act as a perpetrator in an abusive relationship? Select all that apply. 1 He uses physical aggression because he hates his partner. 2 He forces his partner to work because he feels idle. 3 He feels more powerful when he uses force and abuse. 4 He feels he is in charge and dominant in the relationship. 5 He imposes restrictions due to extreme pathological jealousy.
3 He feels more powerful when he uses force and abuse. 4 He feels he is in charge and dominant in the relationship. 5 He imposes restrictions due to extreme pathological jealousy.
The nurse is developing a plan of care for a person who is hostile, demonstrates poor social skills, and is addicted to substances. What would be an appropriate nursing diagnosis for this person? 1 Anxiety and hopelessness 2 Dysfunctional family process 3 Ineffective individual coping 4 Ineffective role performance
3 Ineffective individual coping
A person with a history of abusing an intimate partner says, "When my partner leaves home, I think it's because she's meeting someone she likes better than me." Which emotion is most evident by this comment? 1 Guilt 2 Anxiety 3 Jealousy 4 Remorse
3 Jealousy
In the context of abuse assessment, on which areas should a nurse concentrate? Select all that apply. 1 Assessment by a group of interviewers 2 Approaching the abuser 3 Levels of anxiety and coping responses 4 Observations of the family's patterns of coping 5 Indications or patterns of violence
3 Levels of anxiety and coping responses 4 Observations of the family's patterns of coping 5 Indications or patterns of violence
Which data obtained during a family assessment could be considered an early indicator of the greatest potential for family-focused abuse? 1 The oldest child is legally blind. 2 The children often play violent video games. 3 The mother's brother is in jail for assault and battery. 4 The father travels for work and is home only on weekends.
3 The mother's brother is in jail for assault and battery.
A nurse delivered a lecture at a community health center on interventions to reduce family abuse. The nurse asks the participants about what they learned from the session. Which statement given by the participants indicates effective learning? 1 "The violent behavior of the victim provokes the abuser to abuse." 2 "One should not interfere with others' family abuse cases." 3 "Violence occurs only between heterosexual partners." 4 "Victims are not believed when they disclose their situation."
4 "Victims are not believed when they disclose their situation."
A person was admitted at a health care facility following a suicide attempt resulting from family violence. After the crisis is resolved, what should be the next intervention? 1 Give the patient an outpatient referral. 2 Refer the patient to an inpatient psychiatric unit. 3 Identify the perpetrator and have him or her arrested. 4 Ask the patient if he or she has a plan to repeat this.
4 Ask the patient if he or she has a plan to repeat this.
When planning care for a woman who has been in an abusive relationship for five years, the nurse facilitates the woman's sense of empowerment when: 1 Offering the woman several different suggestions regarding how to stop the abuse. 2 Asking the woman to identify behaviors that trigger her partner's violence. 3 Suggesting that the woman needs to leave the abuser immediately. 4 Assisting the woman in developing a plan to assure her safety.
4 Assisting the woman in developing a plan to assure her safety.
From a psychosocial perspective, the nurse is most troubled when witnessing the parents of 6-year-old twins ignoring the boys being physically aggressive toward each other because this behavior: 1 Suggests that the family has very weak social skills. 2 Indicates a severe lack of parental attachment to the children. 3 Greatly increases the risk of the children being physically injured. 4 Can lead to the children developing violence as a coping mechanism.
4 Can lead to the children developing violence as a coping mechanism.
What is the most appropriate statement about the victims of abuse? 1 Elder abuse is uncommon. 2 Children face physical abuse more than any other abuse. 3 Girls facing child abuse die at a slightly higher rate than boys. 4 Females face intimate partner abuse more often than males.
4 Females face intimate partner abuse more often than males.
A nurse is caring for a pediatric patient who has severe injuries on his or her face and neck. The nurse says to the nurse manager, "I empathize with the patient; I wish I could make this patient happy by resolving all the problems." What response does the nurse have to the patient? 1 Embarrassment 2 Confusion 3 Discouragement 4 Helplessness
4 Helplessness
What nursing intervention can be incorporated to assist parents in stopping the use of corporal punishment to discipline their child? 1 The child is separated from its parent and sent to boarding school to stop the abuse. 2 The parents are threatened that a legal action will take place in case of further abuse. 3 The child is given a help line number to call in case of any further abuse by the parents. 4 Parents are referred to parenting resources to learn alternative approaches to discipline.
4 Parents are referred to parenting resources to learn alternative approaches to discipline.
The nurse is physically assessing a 7-year-old who is suspected of being physically abused. Which observation supports this diagnosis? 1 The child stutters when answering questions. 2 The father refuses to leave his child alone with the nurse. 3 The mother informs the nurse that the child is very clumsy. 4 The child has bruises in various stages of healing on his or her arms.
4 The child has bruises in various stages of healing on his or her arms.
Which statement reflects a fact about family violence? A. Ninety-five percent of abuse victims are women. B. The victim's behavior is often the cause of the violence. C. Violence occurs in families of all backgrounds. D. Alcohol and stress are the major causes of abuse.
C. Violence occurs in families of all backgrounds.
Which statement made by a parent of a child diagnosed with Tourette's syndrome would be assessed as a risk factor for family violence? A. "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs." B. "Our son is really a good little boy, but he needs to be disciplined both at home and in school." C. "We shouldn't be, but we are ashamed of our son's disorder and his inability to control the tics in public." D. "We have become active in the support group but still find the suggestions extremely difficult to put into practice."
A. "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs."
Which factor is of least importance as a victim of spousal abuse constructs an escape plan? A. How the victim will explain her decision to leave B. Where the victim will go to be safe C. How the victim will arrange for transportation D. What the victim will need to take with her when she leaves
A. How the victim will explain her decision to leave
A battered woman has been referred to a women's shelter. When the woman's abuser demands to be told where she is, the nurse A. refuses to provide any information. B. gives him the telephone number, but not the address, of the shelter. C. informs him that no information can be given for a minimum of 24 hours. D. calls law enforcement to arrest the husband for the assault and battery of his wife.
A. refuses to provide any information.
The risk of elder abuse in a home is best determined by assessing A. the vulnerability of the elder and the stress of the caregiver. B. the amount of disruption the elder causes in the home. C. how much actual physical assistance the elder needs on a daily basis. D. the financial contribution of the elder and the caregiver's early life experience with abuse.
A. the vulnerability of the elder and the stress of the caregiver.
Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present: A. with vague physical complaints such as insomnia or pain. B. with extreme anger and unpredictable behavior. C. with many family members there to support them. D. with psychosis and/or mania as a result of long-term abuse.
A. with vague physical complaints such as insomnia or pain.
A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence
ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.
After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner
ANS: A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety.
The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused.
ANS: A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.
An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents
ANS: A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements.
Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner."
ANS: A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.
An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision
ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.
Select all that apply. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult."
ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.
Select all that apply. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? a. Keep a cell phone fully charged. c. Have the phone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.
ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.
What feelings are most commonly experienced by nurses working with abusive families? b. Helplessness regarding the victim and anger toward the abuser
ANS: B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.
An older adult with Alzheimer's disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? b. Alzheimer's disease
ANS: B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk.
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? b. Strong negative feelings interfere with assessment and judgment.
ANS: B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference.
A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: b. name two community resources for help.
ANS: B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.
An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? b. Secure additional resources for the mother's evening and night care.
ANS: B The patient's caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.
Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? c. A women's shelter
ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.
What is a nurse's legal responsibility if child abuse or neglect is suspected? c. Report the suspicion according to state regulations.
ANS: C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.
An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? c. Emotional
ANS: C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.
Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: c. bruises on extremities.
ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.
An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? c. Physical
ANS: C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.
An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? c. Honeymoon
ANS: C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.
A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? d. Document injuries with a body map.
ANS: D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.
An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? d. Physical injuries
ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.
Lauren brings her 4-year-old daughter, Mikayla, to the emergency department and states that Mikayla has been "acting funny." Lauren states, "She touches her vagina and rubs herself down there all the time and she never did that before. She drew me a picture showing two people with one on top of the other and said they were 'doing sex' and I saw her acting that out with her dolls too. I didn't know where else to go." Based on Lauren's description, you suspect that: A. this is normal developmental behavior in a 4-year-old child. B. Mikayla has been sexually abused. C. Lauren needs education in parenting skills. D. Mikayla has been exposed to graphic sexual images on television.
B. Mikayla has been sexually abused.
A nursing intervention directed at the psychological needs of an abused woman is to A. encourage the client to immediately leave the abuser. B. affirm that the client did not deserve or cause the abuse. C. provide a referral to social services for economic problems. D. facilitate contact with law enforcement to take legal action.
B. affirm that the client did not deserve or cause the abuse.
When the nurse believes the cycle of abuse is escalating and that a woman may be in severe physical danger, the priority nursing intervention is to A. advise her to enter counseling at the mental health center. B. assist her to develop a plan to go to a shelter in case of a crisis. C. suggest she leave the abuser and go to a trusted friend's home. D. teach her to counter verbal abuse with assertive replies.
B. assist her to develop a plan to go to a shelter in case of a crisis.
To best assure the safety of a 3-year-old child whose parent admits to finding it difficult to control their anger, the most appropriate short-term goal would be for the parent to A. understand the impact of violence on the child within 2 days. B. begin attending anger management training sessions within 2 weeks. C. state a willingness to attend a support group for physical abusers within 1 week. D. show remorse for their anger management issues within 2 days.
B. begin attending anger management training sessions within 2 weeks.
An abuse victim tearfully tells the nurse in the emergency department, "Don't tell my husband that you know he beats me because if he thinks anyone knows, he will beat me again." Based on this information, the most appropriate nursing diagnosis is A. chronic pain. B. fear. C. post-trauma syndrome. D. risk for self-directed violence.
B. fear
When there is reason to suspect that a child is being abused, the nurse must initially A. call the local police to report it. B. follow agency policy for reporting. C. confront the parent or parents. D. interrogate the child to obtain proof.
B. follow agency policy for reporting.
The nurse performing the assessment of a wheelchairbound client suspects that his wife's explanation of how he sustained facial contusions and a broken nose may not be entirely truthful. The nurse should A. confront the wife with the suspicion that her husband's injuries are the result of abuse. B. have the wife wait in the waiting room so her husband can be interviewed in private. C. report the husband's injuries to the police and ask for a confidential investigation. D. document the suspicion and follow a policy of "wait and see" whether he returns again.
B. have the wife wait in the waiting room so her husband can be interviewed in private.
When treatment for injuries sustained during an incident of abuse is sought from the primary physician, the client is receiving A. primary prevention. B. secondary prevention. C. tertiary prevention. D. stopgap therapy.
B. secondary prevention.
After arranging for a sexual assault nurse examiner (SANE) to see Lauren and Mikayla for further assessment for abuse and proper reporting and followup, Lauren tells you she lives with her boyfriend, Darrin, who is not Mikayla's father. What statement by Lauren would make you suspect she is being emotionally abused? A. "Darrin has a good job and keeps control of all the finances but our electricity still got turned off last week." B. "I didn't tell Darrin I was coming because he is under so much stress at work I didn't want to add to it." C. "Darrin yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." D. "Darrin is Latin American and has a fiery temper."
C. "Darrin yells a lot and calls me names, but that's because I am so stupid and make so many mistakes."
Which child is at lowest risk for abuse? A. A 3-month-old who has colic and teenaged parents. B. A 4-year-old who has cerebral palsy and retarded parents. C. A 2-year-old who has leukemia and two working parents. D. A 5-year-old who has ADHD and a father who was abused as a child.
C. A 2-year-old who has leukemia and two working parents.
What distinction can be made between abuse and neglect? A. Neglect occurs in the psychological domain; abuse occurs in the physical domain. B. Neglect is always physical; abuse can be verbal, physical, sexual, or emotional. C. Neglect is perpetrated against children; abuse victims can be children or adults. D. Neglect is a failure to provide; abuse is a failure to control aggression.
D. Neglect is a failure to provide; abuse is a failure to control aggression.
Which of the following persons has the highest risk factors for physical abuse? A. Emma, a 7-month-old baby who has colic and doesn't sleep through the night B. Roland, a 53-year-old man with cardiovascular disease living with his son C. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder D. Rose, a 77-year-old woman living with her daughter and son-in-law
D. Rose, a 77-year-old woman living with her daughter and son-in-law
If it is determined that Mikayla has been sexually abused, what is the priority outcome for Mikayla? A. Mikayla's mother will learn coping techniques to support Mikayla. B. Mikayla will be able to verbalize exactly what happened to her. C. Mikayla will no longer act out sexually. D. The sexual abuse will cease.
D. The sexual abuse will cease.
An elderly client pays the bills because she fears that her family will make her live elsewhere if she doesn't "help out." The nurse assesses it as A. neglect. B. physical violence. C. psychological abuse. D. financial maltreatment.
D. financial maltreatment.