Chapter 55: Nursing Care of a Family in Crisis: Maltreatment and Violence in the Family

Which of the following is a physical sign of abusive head trauma (shaken baby syndrome)?

*often there are no physical signs* Most children who are victims of abusive head trauma (shaken baby syndrome) show no overt physical signs of abuse. It is only with imaging techniques that the damage is detected.

A nurse is assigned to care for a 7-year-old who has been admitted with infected circular burns to both arms, which resemble cigarette burns. The child states to the nurse, "If I did better in school, this would not happen." What does the nurse understand is most likely the issue with the abusive parents?

*The parents have inadequate parenting skills.* Commonly, abusive parents have inadequate parenting skills. If they have unrealistic expectations of the child, they may not respond appropriately to the child's behavior.

The elementary school nurse is caring for four clients with physical injuries. Which child would require follow-up?

*an 8-year-old with bruising noted on the inner aspect of the arms* Bruising on soft tissue and particularly on the inner aspect of the arms is highly suspicious and would require immediate follow-up and, most likely, reporting. Bruising on the inner aspect of the arms indicates the child was in a defensive position at contact. The other options indicate areas of bruising on bony prominences in alignment with developmental age.

A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client?

*Being nonjudgmental* During the screening process the victim is most likely to be uncomfortable and not want to participate. Victims are concerned about being judged by the interviewer, provoking more violence, and being disappointed by the provider's response to the disclosure. The nurse can best help the victim participate in screening by ensuring confidentiality and being nonjudgmental. There is no guarantee the nurse can assure the woman of help. At best, the nurse can provide information of agencies and services. Having the client be honest about the injuries can cause much distress for the client who may feel it will only lead to more injuries after the partner realizes details have been disclosed. Helping the client find community resources to develop a plan of protection is best done with the social worker and community agencies rather than the emergency room nurse. The nurse should make a referral to the social worker to help with this situation.

When implementing an intervention for a client experiencing intimate partner violence, what is the primary goal?

*The client will regain a sense of control in life.* All goals are positive for the client, but the primary goal when working with victims of intimate partner violence is for them to regain a sense of control in their lives. Control over the victim's life is the primary way an abuser maintains domination in the relationship.

A nurse involved in presenting a community education program that focuses on rape prevention is asked, "Who is likely to commit rape?" What response made by the nurse best demonstrates an understanding of who is likely to commit rape?

*"Research has yet to provide a reliable profile of those who engage in rape."* Assailants, like their victims, come from all walks of life and all ethnic backgrounds; there is no typical profile. What is known is that many assailants have trouble dealing with the stresses of daily life, and are frequently "hot headed." But it is not true that all rapists present with these characteristics. There is no research to support that any male is capable of committing rape.

A 74-year-old client presents with depression, insomnia, and atypical chest pain. When asked about thoughts of suicide, the client states "Yes, I do think about ending all this." What will the nurse do next?

*Ask the client if he or she is being mistreated.* This client is presenting with symptoms of elder mistreatment. The nurse should determine if the client is being mistreated first to know how to properly care for the client. An electrocardiography is not needed as these are symptoms of mistreatment. It is not pertinent to know the history of the client's depression or insomnia. The nurse should know what is going on with the client prior to notifying the health care provider.

A nurse is caring for a client who admits to living in an abusive relationship. Which action would be the priority to meet the client's safety needs?

*Help the client develop an emergency plan to leave.* When working with clients in violent situations, the nurse needs to offer suggestions to help them develop an emergency plan to leave the abusive partner. The plan would include phone numbers of local shelters, making sure the client has keys and gas in the car, and having an escape plan. This is necessary to ensure safety. Referring the client to social services may be helpful in finding resources, but it does not ensure safety. Having a list of shelters is important for the client to have options, but in order to leave the partner the client needs an emergency plan first. Taking a self-defense class will only make the violence worse, as the client is trying to protect herself.

A caregiver who works in the hospital brings his 9-year-old son to the emergency room with a spiral fracture of the tibia. The caregiver reports that the injury occurred when the boy's 5-year-old sister hit him with wooden bat. The injury is inconsistent with an impact and with the sister's strength. Which of the following would be appropriate for the nurse to do in this situation?

*Leave the treatment area and call the social services department in the hospital.* Abusive parents can be found at all socioeconomic levels. When a child is brought to a physician or hospital with abuse injuries, family caregivers may attribute the injury to an action of a sibling. Whenever the child's symptoms do not match the injury the caregiver describes, be alert for possible abuse. State laws require health care personnel to report suspected child abuse (child maltreatment). This requirement overrides the concern for confidentiality. Laws have been enacted that protect the nurse who reports suspected child abuse from reprisal by a caregiver (e.g., being sued for slander) even if it is found that the child's situation is not a result of abuse. If the nurse does not report suspected child abuse, the penalty can be the loss of the nursing license. Do not accuse the caregiver before a complete investigation takes place.

Which of the following is true regarding intimate partner violence?

*One in four women will be a victim of violence.* Approximately 20% to 30% of women will be a victim of violence. Women experience an increase in violence during pregnancy. Abusers often have no outward signs that they are abusers or have a mental illness. Women usually blame themselves and feel they cannot leave the relationship.

A pregnant woman comes to the clinic with a head injury. She tells the nurse that her partner came home drunk and she made him angry by not having dinner ready. He lashed out, she got in the way, and her head hit the corner on the table. What action should the nurse take in this situation?

*Provide the client with contact information for a 24-hour shelter and social worker on discharge.* The nurse should empower the client by making her aware of the resources and options available to her. The client cannot be forced to leave her situation, stay at a friend's home, or to report the abuse.

The nurse notices the caregiver of a 6-year-old child yell at, belittle, and call the child "stupid" and "ignorant" on multiple occasions. Which action will the nurse take first?

*Report the abuse to the client's health care provider.* Psychological maltreatment includes acts such as verbal abuse and belittlement, acts designed to terrorize a child, and lack of nurturance or emotional availability. The nurse would report such findings to the health care provider to determine the plan of care for the client. The nurse would then document the findings. The nurse would not inform the caregiver if child protective services are notified. This could result in the caregiver leaving with the client, placing the client in additional harm. The caregiver may need to be removed from the room; however, this would not be the decision for a client, who is a minor.

The elementary school teacher invites the nurse into the classroom to observe a pupil's interaction when completing an assignment. Which characteristic alerts the school nurse that the child may be the victim of emotional abuse?

*The child is fretful and worried about the project.* When completing group work there can be many dynamics in the classroom; however, the child should not be fretful and worried about the project. This indicates that something else is the cause of the worry. The teacher and school nurse work together to help the child as needed.

The nurse is receiving shift hand-off and is assigned a client who was recently raped. When developing a plan of care, which consideration is most important?

*Victims of rape can find talking about the experience to be therapeutic.* The nurse is correct to begin a therapeutic conversation. Talking about what happened often helps victims cope. Victims usually do not like to be alone after the incident. Often, the victim's usual sexual partner is unable to provide strong support after a rape situation because he or she has difficulty dealing with the situation. Most victims are willing to return for examinations and testing.

A nurse is developing a plan of care for a victim of intimate partner violence. Which intervention would be least appropriate for the nurse to include?

*assisting the client to project anger* The goal of intervention is to enable the victim to gain control by providing sensitive, predictable care in an accepting setting. Assisting the client to project anger would not be helpful when the client needs support and education.

The nurse is caring for a client who was raped approximately 10 hours ago. The client states, "I do not want to have a baby by whoever did this to me." Which action will the nurse do next?

*notify HCP* The nurse should notify the health care provider to determine if the client can be prescribed an emergency contraceptive pill. The effectiveness of the medication decreases every 12 hours after the rape occurred; therefore, the client needs this medication as soon as possible. The nurse would then complete the assessment. The victim should seek counseling, but more information is needed to determine the client's religious preference before having a chaplain come to speak with the client. Performing a pregnancy test at this time is not indicated. The test would not be positive this soon after the event or, if the client were pregnant before the rape, the medication will not have an effect on that pregnancy.

A nurse is assessing an 8-year-old child who was recently found to have been molested by a neighbor. Which nursing action will help the child work through this experience?

*playing with puppets* Molestation is a vague term that includes "indecent liberties" such as oral-genital contact, genital fondling or viewing, or masturbation. For an 8-year-old child, it may be difficult to talk about the experience. By providing an outlet for expression such as using puppets, the child may be able to express what has happened to them and work through the experience. Drawing a picture of a fun time does not address the situation currently. Watching a video and playing a board game do not open lines of communication about the experience.

When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?

*tension-building* During the first phase of intimate partner violence, tension-building, the victim attempts to keep the situation from exploding based on the belief that the partner's anger is legitimately directed at him or her. The battering phase involves the explosion of violence. The honeymoon or reconciliation phase is manifested by a period of calm, loving, contrite behavior on the part of the batterer. The batterer may be genuinely sorry for the pain caused.