Chapter 9: Violence and Abuse

The nurse is caring for a client suspected of being a victim of human trafficking. Which question, when given priority by the nurse during the admission interview, demonstrates a need for additional training?

"Are you working toward achieving American citizenship?"

During a prenatal assessment, the nurse observes that the client is quiet and withdrawn. The client keeps asking if her partner can come into the examination room, because the partner does not like to be kept waiting. Which question would be most important for the nurse to ask before the partner comes into the examination room?

"Do you feel safe in your home?"

The nurse gave a presentation about intimate partner violence (IPV) to a local community group. The nurse determines more teaching is needed when a member makes which statement?

"For the victim's safety, the victim has to learn to be careful to not set off the abuser."

As part of a local college awareness program, a nurse is interviewing several of the participants about their views on rape. Which statement by a participant will lead the nurse to determine that additional education about rape is needed?

"Health care providers can prevent pregnancy and sexually transmitted infection transmission after a rape."

The nurse educator is preparing to teach a group of nurses about intimate partner violence (IPV). Which statement will the nurse include in the teaching session?

"IPV is a common form of violence among people in relationships."

The nurse is caring for a pregnant client who states her spouse verbally abuses her. Which response by the nurse is a priority?

"Intimate partner violence often gets worse during pregnancy and stress. Do you have a safety plan in place?"

The nurse is caring for a client who has been a victim of intimate partner violence (IPV) for a few years. The client states, "My partner has been so sweet to me the last few days by telling me how special I am and bringing me flowers. I believe my partner is sorry and will not do this again." How will the nurse respond?

"It may seem better now, but over time, IPV typically becomes accelerated and more dangerous."

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 I will be turned into child services for being a bad mother."

The nurse suspects a client is a victim of intimate partner violence (IPV). Which statement by the client supports the nurse's suspicion?

"My spouse refuses to let me go out to find a job."

A nurse is working with a victim of intimate partner violence. The client has decided that she is going to leave the relationship. Which instructions by the nurse would be most appropriate? Select all that apply.

"Remember, it might take you several tries before you succeed." "Let's work on a safety plan so that it is ready for when you leave." "I can offer you choices, but you are the one who has to choose."

A client tells the nurse "My partner is going to stop drinking, so I know I won't be hit again." What is the nurse's best response?

"Violence is a learned behavior, not caused by alcohol."

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

A nurse is assessing a victim of rape. Further assessment reveals that the client received rohypnol. The nurse understands that this drug can lead to memory loss for up to how many hours?

8

The nurse is caring for a client who was raped 3 hours ago. Which intervention is a priority for the nurse to perform?

Administer prescribed emergency contraceptive pills.

A client at 36 weeks' gestation presents in the emergency department with a broken arm. The client states, "I fell while cooking dinner." During the assessment, the nurse notes no prenatal care for this pregnancy, as well as bruises in multiple stages of healing on the client's abdomen, arms, and chest. What action will the nurse perform next?

Ask the client how she acquired the bruises

A nurse is performing a physical examination of a pregnant woman. During examination, the nurse notices a bruise on the client's abdomen. Which action should the nurse take?

Ask the client to account for the bruise.

The nurse is assessing a client whose partner is present. The nurse notes the partner swears and yells, makes lavish promises, and threatens to hit the client. Which nursing intervention is a priority?

Ask the partner to leave the room.

A pregnant client discloses to the nurse that she has been abused by her spouse for the past 4 years. Which action will the nurse take next?

Assess the client for signs of intimate partner violence.

When initiating care for a client suspected of being a victim of human trafficking, what is the nurse's primary responsibility?

Building trust

To properly assist a victim of intimate partner violence, which action would be most appropriate for the nurse to do?

Document the details.

A client with multiple bruises comes to the clinic for treatment. The client appears withdrawn and quiet when communicating with the nurse. The spouse accompanies the client to the exam room and begins to answer all the questions the nurse asks the client. Which action will the nurse take next?

Escort the client to a private area to complete the assessment.

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

Explain to the client how to develop a safety plan for leaving the relationship.

The nurse is caring for a client believed to be a victim of human trafficking. What action is most important for the nurse to perform?

Gain the client's trust.

A client at 34 weeks' gestation comes to the clinic with her partner and reports neck and back pain. During the assessment, the nurse notes multiple contusions in various stages of healing on the client's torso and weight gain of 3 lb (1.36 kg) during the course of the pregnancy. Which action will the nurse take next?

Have the client's partner leave the room during the examination.

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.

A nurse is preparing a presentation for a local community group about intimate partner violence. Which statement would be most appropriate for the nurse to include in the presentation?

Intimate partner violence in lesbian, gay, bisexual, transgender, queer (LGBTQ) relationships may go unreported for fear of harassment.

A 19-year-old male client is brought to the emergency department after being raped. Which nursing action is most appropriate at this time?

Listen to the client's description of what happened.

The nurse notes injuries indicating intimate partner violence (IPV) when assessing a client. When questioned, the client confirms the nurse's suspicions. Which nursing action is a priority?

Provide the client information on resources for IPV victims.

A client has recently been treated in the emergency department for trauma to the head as a result of intimate partner violence (IPV). The client states to the nurse the desire to go back home to the partner upon discharge. Which action will the nurse take first?

Provide the client with components of an IPV safety plan.

During the assessment, a client states, "I need something to calm my nerves and help me with sleeping. My spouse will not let me look for a job, and when I need money, I am told I cannot have any since I do not work." Which action by the nurse is most appropriate at this time?

Provide the client with education on intimate partner violence.

A nurse is using the SAVE model to assess a client for possible violence. When validating the client, which action would the nurse most likely perform?

Tell the client that the nurse believes the story.

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.

During a prenatal examination the nurse observes bruises on the client's arms and a black eye. When asked about the bruises, the client states, "It was an accident. My spouse just had a bad day at work, and I was late getting dinner prepared. But my spouse is being so kind now; my spouse brought me flowers yesterday. My spouse is looking for a new job, so it will not happen again." This client is in which phase of the cycle of violence?

The honeymoon phase

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant

A nurse is conducting a presentation on violence and abuse for a community health program. When describing this concept, which information would the nurse include? Select all that apply.

Violence against women often goes unrecognized and unreported. In some countries, violence against women is considered acceptable behavior.

The nurse is caring for four clients. Which client will the nurse suspect is a victim of intimate partner violence?

a client whose partner does not leave the client's side or hospital room at any point of the day or night

The nurse is caring for a client who is a victim of sexual violence. How can the nurse best support the necessary grieving process?

actively listening to the client as he or she talks about the experience

When teaching a group of young adults about the cycle of violence, the nurse would describe which behavior as eventually disappearing as the violence becomes accelerated over time?

apologies for the pain and abuse

A nurse is conducting a discussion group at a local women's health center about violence and women. The nurse would include that women are at a higher risk for violence at which time?

during pregnancy

The nurse is reviewing the medical record of a client at 13 weeks' gestation. Which finding most concerns the nurse?

history of intimate partner violence (IPV)

A nurse is working in a local community health care facility where many clients are victims of intimate partner violence. For which sign(s) will the nurse assess to determine if a client is a victim? Select all that apply.

mental health disorders such as depression, anxiety, or substance use disorder injuries on the face, head, and neck reported history of the injury inconsistent with the presenting problem

The nurse who has experience in caring for victims of intimate partner violence knows that goals for a victim may fall into which categories? Select all that apply.

primary prevention secondary prevention tertiary prevention

A nurse is describing the cycle of violence to a group at a community clinic. The nurse determines that the attendees have understood the information when they identify which phase as usually lasting the longest?

tension building

Nurses sometimes have difficulty assessing clients for intimate partner violence. Which screening protocol is most thorough when assessing for violence?

the SAVE model

A nurse has experienced success by utilizing the SAVE model to evaluate clients for possible intimate partner violence. Which action would be least appropriate for the nurse to address?

validating that the client is the cause

A nurse is screening a client for intimate partner violence using indirect questions. Which question would the nurse most likely ask?

"Clients with your injuries are often abused. Is anything like this happening now?"

A new nurse in the emergency department is caring for a pregnant woman who was beaten by her partner. Which statement by the new nurse would require intervention from the supervising nurse?

"That woman must be doing something to get beaten like that."

The nurse is caring for a client in an abusive situation. In developing a plan of care, which factors does the nurse consider? Select all that apply.

It often takes several attempts before a woman leaves an abusive situation. Women in abusive relationships usually feel isolated and unsupported. Substance use is a common factor in abusive relationships.

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.

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.

A nurse is caring for a 16-year-old immigrant. The nurse wishes to asses if the client is a victim of human trafficking. Which questions should the nurse ask? Select all that apply.

"Can you leave your job or situation if you wish?" "Can you come and go as you please?" "Is there a lock on your door at home so you cannot get out?"

The nurse is talking to a client who is a survivor of intimate partner violence. The client states that the spouse has the characteristics of antisocial personality disorder. The client also informs the nurse that the spouse has an extensive criminal record. The nurse interprets this information and suspects that the client's spouse would demonstrate which behavior?

moderate to severe violence with people both within and outside the family

A nurse is providing care to a victim of intimate partner violence. Applying the ABCDEs of care, place the actions in the order that reflects this framework from first to last. Use all options.

Reassure the victim that he or she is not alone. Express the belief that violence against women is not acceptable. Ensure confidentiality of information. Document the findings. Provide education about the cycle of violence. Ensure that the victim has resources and a plan of action for when he or she decides to leave.

The nurse who counsels clients who suffer from intimate partner violence (IPV) understands that IPV can come in which form(s) of abuse? Select all that apply.

emotional abuse physical abuse financial abuse sexual abuse