Exam 3- Trauma Pearson

A staff nurse educator is presenting an inservice to staff members regarding the risk of violence and healthcare workers. What factors will the educator include in the​ presentation? Select all that apply. Healthcare workers will care for perpetrators and victims when they are most vulnerable. Strong connections between​ aggression, fear, and stress are biologically based. Assault and murder typically leave the individual feeling powerless and angry. Chronic physiological activation in response to stress can cause an aggressive personality. Victims and perpetrators of violence being treated in healthcare agencies act out their frustrations.

Healthcare workers will care for perpetrators and victims when they are most vulnerable. Assault and murder typically leave the individual feeling powerless and angry. Victims and perpetrators of violence being treated in healthcare agencies act out their frustrations. Rationale ​Violence, including assault and​ homicide, specifically impacts healthcare workers because most clients who are involved in assault and homicide will be treated in their community agencies. Healthcare workers provide quality care to victims and perpetrators alike.​ Statistically, healthcare workers are at the greatest risk for violence in the workplace with nurses being at particular risk. Assault and murder typically involve violent reactions to social interactions in which participants have unequal power. This includes clients in hospital settings who feel that their power has been taken away. Clients can feel frustrated as they try to navigate the healthcare system. They may react with violence toward a healthcare​ worker, a​ nurse, who is trying to help them. Biological and psychological connections to​ aggression, fear, and stress exist in humankind generally.

The nurse is providing care to a client who was severely injured as the result of a motor vehicle crash​ (MVC). The client was the driver and the spouse died as the result of the accident. The client is exhibiting symptoms of grief. Which nursing action is most appropriate for this​ client? Help the client understand that working through feelings about what occurred is an ongoing process. Let the client know that anger directed toward the staff is not a positive way to deal with the MVC. Tell the client that his family and friends will be his support system in this situation. Ask the health care provider for an inpatient psychiatric referral.

Help the client understand that working through feelings about what occurred is an ongoing process. Rationale: Working through grief and the process of change is an ongoing process and should not be assigned a time frame. During the anger​ phase, clients may have bursts of anger that the staff should understand and work to facilitate a positive resolution. While the physician may be consulted about the client​'s ​behaviors, the first step would not be an inpatient psychiatric referral. The client​'s family and friends are also affected by the client​'s injuries and the death of the​ spouse, and they may not be able to support the client. The client and the family and friends may need counseling as individuals as well as in a group.

The community health nurse would like to implement community interventions to decrease the number of assaults and homicides that have occurred in the community over the past year. Which actions by the nurse are appropriate to meet this​ goal? Select all that apply. Hold programs at neutral locations outside the community. Involve community professionals from​ schools, health​ departments, law​ enforcement, social services. Teach children when bullying is appropriate. Offer school safety and anger management programs. Identify​ at-risk youth.

Involve community professionals from​ schools, health​ departments, law​ enforcement, social services. Offer school safety and anger management programs. Identify​ at-risk youth. Rationale Violence prevention is an important part of the multidisciplinary approach to assault and homicide. Professionals can identify​ at-risk youth and others at risk of committing violence. They can offer​ training, including school safety and anger management programs. At the community​ level, violence prevention involves health department​ nurses, school nurses and​ counselors, social​ workers, protective services​ personnel, law enforcement​ personnel, and workplace programs. Community violence prevention programs take place at​ schools, churches, childcare​ centers, and other community meeting places. There are​ evidence-based curricula that nurses and other professionals can​ offer, including bullying prevention programs that teach children why bullying is inappropriate.

Jared​ Smith, age​ 17, is the victim of an assault and is admitted to the emergency department. His clinical manifestations are​ inflammation, swelling,​ pain, and bruising. Which etiology is the most likely cause of​ Jared's symptoms? Internal bleeding due to blunt force trauma Abdominal stab wound Bone fractures due to a physical attack Gunshot wound to chest

​Inflammation, swelling,​ pain, and bruising are clinical manifestations of bone fractures resulting from physical attack. Clinical manifestations of a gunshot wound are​ shock, profuse​ bleeding, pain, and inflammation. Clinical manifestations of a stabbing are​ shock, bleeding,​ pain, and inflammation. Clinical manifestations of internal​ bleeding, as a result of blunt force​ trauma, are​ shock, dizziness,​ confusion, abdominal​ pain, and chest pain.

Revised Trauma Score (RTS)

Components: -Glasgow Coma Scale (GCS) -Systolic blood pressure -Respiratory rate Physiological scorring identifies patients who should be treated in Trauma Center (score of <4) Do not let it interfere with patient care

The nurse is caring for a client involved in a motor vehicle crash that sustained an intracranial hemorrhage. The client's condition is deteriorating and the nurse notes that the client's intracranial pressure is rising to dangerous levels. This assessment finding would indicate that the physician is considering which treatment? Physical therapy Occupational therapy Surgery A blood thinner

Surgery Rationale: Intracranial pressure (ICP) will be monitored when a head injury is present, and if the pressure rises to dangerous levels, surgery will be performed to release some of the pressure. The client has an intracranial hemorrhage, therefore, administering a blood thinner would be contraindicated. While therapy and occupational therapy may be required for this client, it is not of immediate concern based on the findings.

Secondary Trauma Assessment includes F G H I

-Full set vitals/ Focused Adjunct/Family Presence -Give Comfort measures (pain) -History (MIVT), Med Hx, Head-Toe assessment -Inspect posterior surfaces

The nurse has been working with a teenage female client who was assaulted and robbed late one night after shopping. Which outcome indicates that the client has achieved the expected outcomes of treatment? (Select all that apply.) The client is enrolling in a self-defense class for women. The client states that she will shop only when there is someone to accompany her. The client talks about the event without excessive distress. The client states a plan to choose parking spaces close to a building. The client states that she will no longer shop.

-The client is enrolling in a self-defense class for women. -The client talks about the event without excessive distress. -The client states a plan to choose parking spaces close to a building. Rationale: The client demonstrates effective coping by talking about the event without distress, making a plan for shopping, and by enrolling in a self-defense class. Not shopping at all or only with company demonstrates unresolved anxiety over the event.

Which is the most significant assessment finding in a client with major trauma following a motor vehicle accident? O2 saturation Level of orientation Pulse rate Ability to speak

Ability to speak Rationale: Using the ABCs, the client's ability to speak indicates an open airway. While the other options are important assessments, they are not directly indicative of the presence of a patent airway.

Severe facial injuries, such as those resulting from going through the windshield of a car, increase the risk for all of the following. Which would the nurse assess for first? Airway obstruction Hemorrhage Fractures Contusions

Airway obstruction Rationale: The first priority is always the airway. Assessing the airway and initiating interventions are the first steps in managing a client who has been in a motor vehicle crash. Although checking for hemorrhage, contusions, and fractures is important, a patent airway is the number-one priority for survival.

Which finding indicates a positive outcome in the treatment of a client who suffered trauma injuries from a motor vehicle crash? An oxygen saturation of 90% on room air A respiratory rate of 36 An oxygen saturation of 96% on 2L NC A pulse rate of 140

An oxygen saturation of 96% on 2L NC Rationale: An oxygen saturation of 96% on 2L NC would be a desired outcome for a client. A positive outcome for a client would be maintaining an oxygen saturation of greater than 95%; therefore an oxygen saturation of 90% on room air would not be a desired outcome. It is also desired that the respiratory rate and pulse rate maintain within normal limits. The pulse rate of 140 and respiratory rate of 36 are not within normal limits. .

The nurse is providing care to a pediatric client who is the victim of an assault that occurred on the way home from the store. Which factors may have caused the client to become the victim of​ assault? Select all that apply. Winter months Consumption of alcohol Good relationship with neighbors Weekends Unequal power in social interaction

Consumption of alcohol Weekends Unequal power in social interaction Rationale Assault and murder typically involve violent reactions to social interactions in which participants have unequal power. There are higher rates of homicide on​ weekends, during the​ summer, and during other periods of higher interaction when alcohol is consumed. An upheaval in a relationship is a warning​ sign, not a good relationship.

A client suffered a traumatic​ above-the-elbow amputation of his left arm as the result of a motor vehicle crash​ (MVC). The client is​ withdrawn, does not look at the injured left​ arm, and asks to be left alone. Which nursing diagnosis is the priority for this ​client? Altered physical activity Impaired respiratory status Potential for flexion contracture Disturbed body image

Disturbed body image Rationale Clients with a traumatic amputation will often have a disruption in body image due to the grieving process. Because the amputation is above the​ elbow, the possibility of a flexion contracture is not likely. His ability to be physically active will not be significantly altered because the amputation involved an upper extremity. Impaired respiratory status is also not likely to occur with an amputation.

A​ 5-year-old girl who has been physically abused is having difficulty putting her feelings into words. Which nursing intervention best enables the child to express her​ feelings? Reporting the abuse to a prosecutor Engaging in play therapy Giving the child​'s drawings to the abuser ​Role-playing

Engaging in play therapy Rationale The toys and dolls in a play therapy room are useful props to help the child remember situations and​ re-experience the​ feelings; acting out the experiences with toys rather than putting them into words is sometimes easier for the child.​ Role-playing for a younger child is​ difficult, especially without the use of toys or dolls. Giving the drawing to the abuser can put the child in danger. It is the nurse​'s responsibility to report suspected child abuse to the proper​ agency, but the reporting does not help the child express her feelings.

Glascow Coma Scale Eyes (4) Verbal (5) Motor (6)

Eyes (4) 4-Open Spontaneously 3-Open to Verbal 2-Open to Pain 1-None Verbal (5) 5-Oriented 4-Confused/ Answers questions 3-Inappropriate/ discernable 2-Incomprehensible 1-None Motor (6) 6-Obeys commands 5-Purposeful movements 4-Withdraws from pain 3-Decorticate/ Flexion/Spastic 2-Decerebrate/Extension/Rigid 1-None

An adolescent who has a gunshot wound to the head is being admitted to the critical care unit from the emergency department. Which of the following assessment findings are indicative of increased ICP? Headache Dilated pupils Tachycardia Decorticate posturing Hypotension

Headache Dilated pupils Decorticate posturing Rationale: Headache, dilated (or pinpoint) pupils, and decorticate (or decerebrate) posturing are signs of increased ICP. Bradycardia and hypertension with a whitening poles pressure or signs of increased ICP as opposed to tachycardia and hypotension.

A client who is paralyzed from severe injuries sustained during an automobile accident continually attempts to perform activities beyond capabilities. Which is the most appropriate nursing diagnosis for this client? Disturbed image Risk for trauma Anxiety Ineffective denial

Ineffective denial Rationale: The client is exhibiting signs of denial by failure to adjust to the limitations of paralysis. The client may have anxiety and a disturbed body image, but the priority here is the denial. The client is not at risk for trauma since that has already happened.

The nurse in the emergency department is caring for a woman of Asian descent who was brought in by a neighbor. The right side of the client​'s face is​ swollen, bruised, and bleeding. She has multiple bruises on her arms. The client​'s husband arrives and does not let her​ speak; he answers questions for her. The nurse should suspect which type of​ abuse? Intimate partner violence Elder abuse Rape Financial abuse

Intimate partner violence Rationale The nurse should suspect intimate partner violence based on the client assessment and the husband​'s controlling behaviors. Elder​ abuse, rape, and financial abuse are not in evidence at this time.

A nurse is caring for a client who was recently admitted to the emergency department following a head on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, And a laceration on his four head that is bleeding. Which of the following is the priority nursing action at this time? Keep neck stabilized Insert NG tube Monitor pulse and blood pressure frequently Establish IV access and start fluid replacement

Keep neck stabilized The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. Priority nursing intervention is to keep the neck in mobile until damage to the cervical spine can be ruled out. Inserting an NG tube, monitoring pulse and blood pressure, and establishing IV access for fluid replacement are all important, but not the priority at this time.

A 10-year-old client was admitted to the hospital with a gunshot wound to the abdomen sustained in a drive-by-shooting. The nurse knows that which intervention is priority when caring for a client with a gunshot wound? Monitoring for bleeding and controlling hemorrhage Monitoring for signs and symptoms of infection Performing wound care Referring the client to physical therapy for evaluation

Monitoring for bleeding and controlling hemorrhage Rationale: Injuries need to be treated in order of severity. Priorities for the treatment of a gunshot wound include, maintenance of the airway, controlling hemorrhage, and preventing hypothermia. When caring for clients who have been assaulted nurses do focus on infection control, health maintenance, and recovery. While monitoring the wound for signs of infection, wound care, and rehabilitation are all a focus of care, they are not the priority.

A nurses caring for a client who has just been admitted from surgery for the evacuation of a subdural hematoma. Which of the following is the priority assessment? Glasgow coma scale Cranial nerve function Oxygen saturation level Pupillary response

Oxygen saturation level Rationale: well all of the assessments are important to the care of this client, assessment of the clients oxygen saturation level is the highest priority. Brain tissue can only survive for 3 minutes without oxygen before permanent damage occurs.

The nurse is providing discharge instructions to a client who is recovering from low back pain that resulted from a motor vehicle crash​ (MVC). Which instruction is the priority for this​ client? Perform daily exercise as instructed as a lifelong routine Avoid occupations that require physical use of the body Sit in a chair with the hips higher than the knees Sleep on the abdomen or on the back with legs extended flat on the bed

Perform daily exercise as instructed as a lifelong routine Rationale Prescribing daily exercise is an important part of healing from a back injury. Clients should sit with the knees higher than the hips and should sleep in a​ side-lying position with the knees and hips bent or on the back with a pillow to flex the knees. The client should use good body mechanics and proper transfer techniques in any job activity.

The nurse on the pediatric unit is caring for a​ 3-year-old child who has​ dime-size burns on her legs and bruises in various stages of healing on her abdomen and back. Which is an appropriate nonpharmacologic treatment for this​ child? Assess the child​'s back and abdomen for any changes. Refer the child for play therapy. Give acetaminophen as ordered by the physician. Treat the burns with silvadene ointment.

Refer the child for play therapy. Rationale Appropriate nonpharmacologic interventions for abused or neglected children include​ play, cognitive,​ behavioral, and group therapy depending on the age of the child. Acetaminophen and burn ointment are pharmacologic treatments. Assessing the child​'s back and abdomen is part of the nursing assessment that is done each shift.

The nurse is aware that changing levels of hormones and neurotransmitters may contribute to violent behavior. Which elevated level would cause the nurse to be concerned about a potential for violence in a client? Serotonin Dopamine Testosterone Cortisol

Testosterone Rationale: Higher testosterone levels may cause a deficit in serotonin levels, which, in turn, causes people to react more aggressively to annoying situations. Serotonin exerts inhibitory control over aggression. Lower levels of serotonin, not higher, are associated with more aggressive behavior. Dopamine appears to be inversely associated with aggressive behavior, meaning that low levels of dopamine may cause more aggressive behaviors. Low cortisol levels, not higher levels of cortisol, have been associated with greater antisocial behavior.

The nurse at a local hospital is working with a coalition of local organizations on violence prevention after a series of assaults and murders by members of youth gangs in the community. Which intervention is appropriate for the nurse to offer the​ community? Home visits Anger management Undercover police infiltration ​Hospital-based program

The nurse would offer a multidisciplinary​ approach, problem solving​ education, and anger management to the community. A​ hospital-based program is not appropriate for a​ community-based program to decrease violence within the community.

A nurse is assessing an older adult client who was being abused and neglected. The nurse should assess the client for which​ characteristics? Select all that apply. Chronic fatigue Trauma to sexual organs Withdrawn behavior Bruises or burns Malnutrition

Trauma to sexual organs Withdrawn behavior Bruises or burns Malnutrition Rationale ​Bruises, burns, and malnutrition are manifestations of physical elder abuse and neglect. Withdrawn behavior is a symptom of emotional elder abuse. Trauma to sexual organs is a symptom of sexual abuse of older adults. Chronic fatigue is not associated with elder abuse.

A forensics nurse is preparing a presentation to educate members of the community to decrease their risk of being involved in a violent crime. Which locations will the nurse include in the presentation that place an individual at a higher risk of assault or​ homicide? Select all that apply. Suburbs Urban area Southern states Economically challenged area Rural area

Urban area Southern states Economically challenged area Rationale Urban centers are more violent than rural areas or the suburbs. The Southern U.S. has more violence than other areas of the country. A person is more likely to be a victim​ of, or engage​ in, assault or homicide if that person is living in poverty or in an economically depressed area.

Which intervention is of highest priority in preventing infections in a multiple trauma victim? Assessment of temperature every 3-4 hours Providing a diet high in calories and protein Changing the client's dressing every shift Washing hands before all client contact

Washing hands before all client contact Rationale: Hand washing before contact with a patient is the best way to prevent infection in a hospitalized client. Assessment of temperature is assessment, not prevention. Providing a diet high in protein promotes healing of wounds. Changing a dressing every shift also promotes healing.

A nurse is working in an emergency department and is being trained on diagnostic tests used for various cases of abuse. Which diagnostic tests should be included for​ physical, not​ sexual, abuse? STD testing HIV testing Vaginal swabs ​X-rays

​X-rays Rationale ​X-rays are used to identify old and new fractures associated with physical abuse. STD and HIV testing and vaginal swabs are used in the evaluation of sexual abuse.

First Trauma Assessment Includes A B C D E

Airway/C-spine Breathing Circulation Disability/Neuro Expose/ Environment

The nurse is triaging a group of clients who were involved in a​ multiple-car accident during​ rush-hour traffic. Several clients are being admitted to the emergency department. Which​ clients, based on cultural or religious​ beliefs, may refuse treatment from the health care​ staff? ​(Select all that​ apply.) ​Jehovah's Witnesses Jews Muslims Christian Scientists Christians

​Jehovah's Witnesses Christian Scientists Rationale: There are some populations that may refuse treatment on religious or cultural grounds. For​ example, Christian Scientists will often not allow mainstream medical​ intervention; and​ Jehovah's Witnesses will often refuse blood transfusions. Other populations may believe in traditional medical systems and may refuse standard treatments offered by contemporary Western medicine.

The nurse is prioritizing care for clients who have been assaulted during a mass shooting at a local mall. Which client will require priority care based on assessment​ findings? A client with an open stab wound to the forearm A client with abdominal bruising A client with a bullet wound to the throat A client with an open fracture of the femur

A client with a bullet wound to the throat Rationale The nurse prioritizes care based on the initial assessment of the clients who present for care. A client with a bullet wound to the throat would require priority intervention because this client is at risk for airway issues and circulatory issues. While the other clients will require​ care, this client takes priority over other clients at this time.

The nurse is caring for a client who experienced a blunt force trauma to the abdomen. The client​'s vital signs are​ stable, but the client is complaining of significant pain. Which nursing intervention is the priority for this​ client? Administer analgesic​ medication, per order Palpate the abdomen Assess blood pressure Monitor stool for blood

Administer analgesic​ medication, per order Rationale Based on the assessment​ findings, the nurse would administer an analgesic medication to address the client​'s pain. While it is appropriate for the nurse to monitor the stool for blood and assess the blood​ pressure, these are not priority at this time. The nurse would not palpate the abdomen after a blunt force trauma unless instructed to do so by the healthcare provider.

The nurse assesses a client who was involved in a motor vehicle crash​ (MVC). The nurse documents tachypnea and dyspnea. Which nursing diagnosis will the nurse use to plan appropriate interventions for this​ client? Altered respiratory status Altered circulatory status Altered gastrointestinal status Altered neurological status

Altered respiratory status Rationale: The assessment findings indicate altered respiratory status. The nurse will plan interventions based on this nursing diagnosis. The other diagnoses are not supported by the assessment findings.

The nurse is caring for a client experiencing seizure activity after a motor vehicle crash​ (MVC). Which diagnostic test does the nurse anticipate will be ordered for this​ client? A UA An EEG An ECG ECT

An EEG​ Rationale: An EEG​ (electroencephalogram) can be used to diagnose changes in brain activity. ECT is electroconvulsive therapy and is not a diagnostic test. An ECG shows the electrical pattern of the heart. A UA is a urinalysis and would not assess neurological status.

Ms.​ Burgos, age​ 35, is admitted to the emergency department with a gunshot wound. She reports having been shot by her​ husband, who is still at large. The​ client's vital signs are stable. Which assessment is now the priority for this​ client? Prioritization of client injuries ABCDE assessment Preparation for colonoscopy Safety of client

For a client who is stable from physical injuries related to the​ assault, the nurse will concentrate on the safety needs of the client. ABCDE assessment and prioritization of the​ client's injuries have already occurred. There is no indication that this client requires a colonoscopy based on the assessment data presented.

The nurse would like to teach a group of adolescents about improving safety while driving. Based on the most recent​ statistics, which primary cause of motor vehicle crashes​ (MVCs) will the nurse focus on during the teaching​ session? Health conditions Aggressive driving Human error Weather

Human error Rationale Human error is the primary cause of MVCs. Other risk factors that contribute to the occurrence of MVCs are forces of nature​ (animals entering the​ roadway); weather​ (snow, ice,​ rain, fog); age ​(16dash-19 and over​ 65); speeding​ (driving over the speed​ limit); distracted driving​ (texting, making phone​ calls, putting on​ makeup, eating, dealing with​ children); aggressive driving​ (road rage, arguments with​ passengers, tailgating); health conditions​ (exacerbation of a chronic heart or respiratory disorder or other medical​ condition).

The nurse is providing care to a client who sustained a whiplash injury as result of a motor vehicle crash​ (MVC). Which pharmacologic treatment is most appropriate for this ​client? Sedatives Tocolytics Hydrocodone Lidocaine

Hydrocodone Rationale: The most appropriate pharmacologic treatment for a client who sustained whiplash is a narcotic analgesic like hydrocodone. Lidocaine is appropriate for a client who requires sutures. Sedatives are appropriate for clients who are at risk of further injury as the result of reacting to the current injury. Tocolytics are used to induce labor in pregnant clients.

When interviewing a potentially violent or aggressive client, which environmental factor is most important for the nurse to consider? The client should be told that violent behavior will not be tolerated. The interview should take place in a calm, quiet area to reduce stimuli. Restraint devices should be in full view of the client. Care should be taken to ensure that other staff members do not interrupt.

The interview should take place in a calm, quiet area to reduce stimuli. Rationale: The nurse should ensure that the interview be conducted in a quiet environment. Even minor factors, such as, loud noise can trigger aggression and violence. Reduction of interruptions is advisable but may not be totally possible. Intimidation of the client with restraints and verbal rebukes is inappropriate and may provoke violent behavior.

A client who has been physically abused asks the nurse, "What makes people so violent toward others?" Which is the best response to this question? "Hormones are the primary reason for violence in men." "Violence is inherited from a person's family." "If women were more agreeable, there wouldn't be any violence." "It is difficult to give one specific reason for violent behavior."

"It is difficult to give one specific reason for violent behavior." Rationale: Many theories exist concerning the motivation for violent behavior and abuse within families. Some of those theories propose that individuals are genetically predisposed to violence, while other theories discuss the influences of society and family structure. No definite causes of family violence have ever been agreed upon, but theories such as the psychopathology theory and the social learning theory lead into one another to help highlight some contributing factors to abusive behavior.

A client who has an open head injury has been prescribed phenytoin (Dilantin) to reduce the risk of seizures. Concurrent use with which of the following medications should be reported to the provider due to the possibility of the medication interaction? Celecoxib (Celebrex) Ciprofloxacin (Cipro) Atorvastatin (Lipitor) Warfarin (Coumadin)

Warfarin (Coumadin) Concurrent use of phenytoin and warfarin can lessen the effectiveness of warfarin. There are no interactions between the others and phenytoin.

The nurse is providing care to a client who received sternal injuries as the result of an airbag deployment after a motor vehicle crash​ (MVC). The client is currently experiencing an abnormal heart rate. Which diagnostic test does the nurse anticipate for this​ client? An MRI scan An ECG An EEG A CT scan

An ECG Rationale The nurse would anticipate that this client would require an ECG to assess any heart damage. An MRI or CT scan would not accurately diagnose cardiac issues in this client. An EEG is used to assess brain injury that can occur during an MVC.

A college student is seen in the emergency department following an incident of date rape. The nurse documents that during her assessment of the​ student, the student describes the entire chain of events with a blank facial expression. She ends her comments by​ saying, open double quote"It​'s like it didn​'t happen to me at​ all." Which order will the nurse expect for this​ client? SSRIs NSAIDs Narcotics Antibiotics

Antibiotics Rationale The nurse will expect an order for antibiotics to treat potential STIs. SSRIs might be indicated in weeks to come if the client develops symptoms of anxiety or depression following the​ rape; these are not evident at this time. The client is not complaining of pain at this time so the use of NSAIDs and narcotics is not indicated at this time.

A client comes to the emergency department with multiple bruises on the face and head. The nurse suspects that domestic violence may be the cause of the injuries. What is the most appropriate initial action for the nurse to take? Ask if the client is afraid of being hurt by someone at home. Call a social worker to evaluate the client for domestic violence. Refer the client to a shelter for battered partners. Document the concern, but do nothing else.

Ask if the client is afraid of being hurt by someone at home. Rationale: Asking if the client is being hurt is a critical step in a comprehensive assessment. Referring the client to a shelter without assessment may be a disservice; the nursing process requires assessment before intervention. After assessment and the determination of domestic violence, collaboration with social services is appropriate. Documenting the assessment does nothing to help the client resolve the issue.

A​ 2-year-old is brought to the pediatric clinic with an upper respiratory infection. After assessing the​ child, the nurse suspects that this child may be a victim of child abuse. Which is a physical sign that usually indicates child​ abuse? Scraped and scabbed knees A few bruises on shins Diaper rash Welts or bruises in various stages of healing on the child​'s back

Welts or bruises in various stages of healing on the child​'s back Rationale The assessment findings in children who are physically abused include bruises and​ welts, in various stages of​ healing, in areas where one does not normally see bruising from being a​ child; whip marks on​ back, legs, or​ buttocks; abdominal pain or​ tenderness; and broken bones or fractures in various stages of healing. Bruises on the lower​ legs, scraped and scabbed​ knees, and diaper rash are normal findings for children at this​ age, who are trying and exploring new things and may still be in diapers.

You are caring for Mr.​ Davis, an​ 84-year-old man who has been hospitalized for malnutrition. You suspect that elder abuse may be responsible for Mr.​ Davis's condition, but when you ask him about the care he receives from his​ caregiver, he tells you he is afraid of what will happen if his caregiver finds out that he is complaining. Which is your best response to Mr.​ Davis? ​"It would be better for you if I share what you tell me with your​ caregiver." ​"I will not share anything you tell me with your​ caregiver." ​"You shouldn't be so afraid of what your caregiver will​ do." ​"It's necessary that I share what you tell me with your​ caregiver."

You would respond to Mr.​ Davis's concerns by telling him that you will not share anything he tells you with his caregiver. Assuring the client of confidentiality will help promote a trusting​ relationship, which is an essential nursing intervention. You would not tell him that it would be better for him if you share what he tells you with his​ caregiver, because this may make him feel unsafe. You would not tell Mr. Davis that​ it's necessary for you to share what he tells you with his caregiver because this is untrue. You would not tell Mr. Davis that he​ shouldn't be afraid of his caregiver because this statement is judgmental and would not promote a trusting relationship between you and Mr. Davis.

Which population groups are most likely to be victims of assault and homocide? Young adult male gang members Children in elementary schools Adolescent females in high school Older adults living alone

Young adult male gang members Rationale: Adolescents and young adults may be the group likeliest to commit and be victimized by acts of assault and homicide. Although violence has become more prevalent in schools, the highest homicide rates and victims of violent crime are seen in older teen and young adult males. Although older adults and adolescent females are vulnerable to violent crimes, the highest homicide rates and victims of violent crime are seen in older teen and young adult males.

The school nurse teaches elementary school teachers about occurrences of violence towards children. The nurse knows that further teaching is necessary if a teacher makes which statement? "Poor hygiene and inappropriate clothing are possible signs of child abuse." "Children who are physically abused by their parents are more likely to abuse siblings." "Physically abused children may appear overly submissive and eager to please their teacher." "Children with special needs are less vulnerable to physical abuse than other children."

"Children with special needs are less vulnerable to physical abuse than other children." Rationale: Caregiver stress and frustration may lead to abuse or even homicide of children with special needs. Children who are physically abused by their parents are more likely to abuse siblings; sibling abuse is the most unrecognized form of abuse. Physically abused children may appear overly submissive and eager to please their teacher; abused children are frequently overly compliant in response to all adults. Inadequate physical care or lack of care for a child may be a sign of child abuse.

The nurse is admitting a​ client, Justin​ Walker, who received potentially​ life-threatening injuries secondary to a motor vehicle collision earlier this evening. Upon moving the client into a trauma examination​ room, which assessment is the priority for Mr.​ Walker? Assessment for neurological injuries Assessment for a patent airway Assessment for orthopedic injuries Assessment for abdominal injuries

A thorough​ head-to-toe assessment is most important in assessing the client involved in an MVC. While assessing for neurological​ injuries, orthopedic​ injuries, and abdominal injuries are​ essential, the first assessment to be made is to ensure a patent airway. Without a patent​ airway, the client cannot survive any other injuries.

The nurse is talking with a client who just had a beautiful potted flower delivered. Suddenly the client starts to cry and stares out the window. The client has a history of abuse by her husband. Which response should the nurse include in the plan of care for this​ client? Tell the client to enjoy the flowers and that she will feel better in a little while. Assess if the client is having a flashback of previous abuse. Tell the client that the abuse was in the past. Give the client some time and return later.

Assess if the client is having a flashback of previous abuse. Rationale Clients who have experienced​ trauma, such as interpersonal or intimate partner​ violence, may experience flashbacks. The flowers may trigger flashbacks for this client. The nurse needs to assess if the client is having a flashback and stay with her to help her cope through the flashback. Leaving the client alone while she is having a flashback of previous events is not​ therapeutic, as the client may feel that she is in danger. Telling the client that the abuse was in the past does not acknowledge the client​'s past experience with abuse. It also does not allow the client to express her feelings about the past events that have occurred.

During the assessment of a client with a spinal cord injury that resulted from a motor vehicle crash​ (MVC), the nurse determines that the client has a poor cough with breathing. Based on this​ finding, which is the most appropriate action by the​ nurse? Prepare the client for intubation and mechanical ventilation. Assess lung sounds and respirations every 1-2 hours. Place the patient in a prone position to promote the drainage of secretions. Use tracheal suctioning to remove secretions.

Assess lung sounds and respirations every 1-2 hours. Rationale: With shallow breathing and ineffective​ coughing, pneumonia and atelectasis are potential problems following a spinal cord injury. The nurse should assess respirations and lung sounds every 1dash-2 hours to determine whether secretions are being retained. Suctioning is not indicated unless the lung sounds become congested. Putting the client in a prone position can compromise respiratory function. The client will be intubated and put on mechanical ventilation only if he or she becomes exhausted or if ABGs deteriorate.

What are appropriate actions for a nurse to take to secure the safety of a trauma team and a client who is being treated for injuries sustained in an attempted​ homicide? Select all that apply. Ask law enforcement or security personnel to be present during treatment. Use chain of custody procedures for specimens. Ensure that the client is free of weapons. Cooperate with law enforcement and security personnel. Do not clean the victim​'s hands.

Ask law enforcement or security personnel to be present during treatment. Ensure that the client is free of weapons. Cooperate with law enforcement and security personnel. Rationale There are situations where clients have the potential to direct violence toward the healthcare team. Hospital staff and law enforcement personnel must cooperate to ensure the safety of the trauma team. Law enforcement or the trauma team must determine that the client is free of weapons before treatment is initiated. In the clinical​ setting, police officers or security personnel may be needed during treatment. Not cleaning the victim​'s hands or the area around the victim​'s wounds and following legal chain of custody procedures are aspects of the preservation of evidence that may be needed to prosecute a​ crime, not an action taken to ensure safety of the trauma team and client.

An older woman who has been physically and financially abused by her son tells the​ nurse, "I am not pressing charges against my son because I am afraid that he will put me out on the street and I will have no place to​ go." Which response should the nurse include in her interventions for this​ client? Assess the client​'s safety and help her develop a safety plan. Instruct the client not to worry about her son because she is in the​ hospital, so he will not do it again. Support the client​'s wishes to not press charges due to fear. Encourage the client to move out of her son​'s home to avoid future encounters with him.

Assess the client​'s safety and help her develop a safety plan. Rationale The client may be at risk for future attacks because she is being abused by someone with whom she lives. The nurse needs to make a thorough assessment of the client​'s safety and assist the client in developing a safety plan in the event the son abuses her again. Having the client move may not be an​ option, as the client may have nowhere else to live. Even though the client is in the​ hospital, she is still in danger. Supporting the client​'s wishes to not press charges due to fear is not a therapeutic intervention.

The nurse is participating in a yearly required​ ride-along with the paramedics who service the hospital emergency department​ (ED). During the​ ride-along, the nurse is treating a​ 45-year-old male​ client, Clyde​ Waters, who has been injured in a motor vehicle crash. Mr. Waters sustained a suspected head injury and the nurse phones the ED to provide a report prior to his arriving at the ED for further treatment. Which diagnostic test does the nurse anticipate will be ordered based on the current assessment​ findings? CT and MRI scans Ice and heat therapy Complete blood count​ (CBC) Basic metabolic panel

A​ CT, MRI and other diagnostic tests would be used to determine the extent of the injury. A complete blood count and a basic metabolic panel are not useful in diagnosing specific head injuries. Ice and heat therapy may be collaborative interventions but are not diagnostic tools.

A father comes to the emergency department after receiving a phone call informing him that his daughter was involved in a motor vehicle crash​ (MVC). When he approaches the triage​ desk, he asks​ frantically, "How is my​ daughter?" Which response by the nurse is most appropriate in this​ situation? ​"She's being examined now.​ She's awake and talking.​ We'll take you to see her​ soon." ​"Your wife called and I told her​ everything, so you can check with​ her." ​"Everything will be​ okay; please take a seat and​ I'll check on her for​ you." ​"Your daughter is young and has youth on her​ side; I'm sure​ she'll be​ fine."

By telling the father that his daughter is awake and​ talking, and being examined by the​ doctor, the nurse provides accurate information and helps reduce the​ father's anxiety. Such responses as​ "I'm sure​ she'll be​ fine" offer false reassurance and fail to respect the​ father's concern. Asking the father to call his wife to discuss their​ daughter's situation with her will only frustrate​ him, as his wife may have misinterpreted what the nurse said.

The nurse formulates a nursing diagnosis of ineffective family processes for the family of a child who has sustained a brain injury during an automobile accident. The nurse is aware that when considering this nursing diagnosis which intervention has the highest priority? Explain the visiting rules of the intensive care unit. Encourage the family to express feelings and ask questions. Teach the family the importance of using seat belts. Refer the family to supportive services in the community.

Encourage the family to express feelings and ask questions. Rationale: It is optimal to find out what the family's perception is of what is going on and what they feel their needs are. The best way to do this is to encourage them to ask questions and express their feelings. While families may need teaching about seat belts and sources of support, now is not the optimal time to institute these interventions. Most pediatric intensive care units have open visiting for the family.

A nurse came to work with a black eye and a swollen lip. Coworkers have noticed that the partner calls the nurse at least 10 times during a 12-hour shift. The nurse has refused all invitations to go out with coworkers, saying that the partner will be there after work and doesn't like to wait. Which action taken by the coworkers would be most helpful? Encourage the nurse to get a restraining order against the partner. Enlist the parents' aid in getting the nurse away from the partner. Encourage the nurse to talk to a professional. Convince the nurse to leave the partner.

Encourage the nurse to talk to a professional. Rationale: Encourage the nurse to talk to a professional. Nurses encourage the client to accept help in seeking an abuse-free living situation, but the decision ultimately lies with the client. Some individuals will not be ready to seek help, and while the nurse may disagree with this decision, he must refrain from judgment and be respectful of the client's decision. All nurses can do in these situations is offer assistance and resources, the victim will then know that help will be available if it is needed in the future. Trying to convince abused adults to leave their abuser does not empower the adult. Friends and coworkers should provide support without telling the nurse what to do. Encouraging the nurse to get a restraining order against the partner is inappropriate because a restraining order may actually increase the violent behavior of the partner. Involving the parents may complicate the situation and result in more abuse, which further isolates the nurse from family and friends.

The nurse is providing care to a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which factors could interfere with the nurse establishing trust during a therapeutic encounter with this​ client? Select all that apply. Hypervigilance Depersonalization ​Irritability, aggressiveness Nightmares Ineffective coping

Hypervigilance Depersonalization ​Irritability, aggressiveness Rationale: Clients with PTSD have experienced traumatization. They may be physically and emotionally isolated. They may be​ irritable, aggressive, emotionally​ numb, frightened, experiencing​ flashbacks, and on high physical and emotional alert during an appointment with the nurse. They may be reluctant to share their thoughts and feelings and should not be pressured to until they feel ready. These clinical manifestations of PTSD make establishing trust with the client a challenge for the nurse. Nightmares are a clinical manifestation of PTSD that does not take place during therapeutic encounters between the client and nurse. Ineffective coping is a problem that may be included in the nursing plan of care for a client with PTSD.

The nurse is planning care for a client who has witnessed a violent assault. Which is a key component of crisis intervention that the nurse should utilize at this time? Teach the client to handle similar future events. Assist the client in forgetting the crime. Identify the client's maladaptive coping mechanisms. Identify the client's coping patterns and then offer support.

Identify the client's coping patterns and then offer support. Rationale: Assisting the client to identify coping patterns and then supporting the client is essential to managing a crisis. Identifying the client's maladaptive coping patterns may be beneficial after identifying strengths, but not initially. Assisting the client to forget is not a therapeutic intervention for crisis management. Teaching the client how to handle similar future events is appropriate after the current crisis has abated.

The nurse is caring for a client who experienced a deep laceration to the arm as the result of an assault. The client is resting comfortably and is denying any pain but will need sutures to close the wound. Which pharmacologic therapy does the nurse anticipate for this client prior to​ suturing? Ibuprofen Penicillin Lidocaine Morphine

Lidocaine Rationale The nurse would anticipate that the client would require local​ anesthetic, such as​ lidocaine, prior to the suturing that will be required to close the wound. The client is not complaining of intense​ pain; therefore, morphine would not be anticipated. The client may be sent home with prescriptions for ibuprofen for pain and penicillin to prevent​ infection, but these medications are not required prior to suturing.

The nurse is conducting a seminar regarding the recent increase in motor vehicle collisions​ (MVCs) within the community. Which statement made by the nurse during the seminar is most​ accurate? MVCs are the primary cause of death in individuals 69-89 years old. MVCs are the primary cause of death in children 0-10 years old. MVCs are the primary cause of death in individuals 28-48 years old. MVCs are the primary cause of death in individuals 11-27 years old.

MVCs are the primary cause of death in individuals 11-27 years old. Rationale: The primary cause of death in individuals 11dash-27 years old is MVC involvement. The other age groups are not correct and the nurse should not include them in the seminar.

Sarah​ Smith, a community health registered​ nurse, is conducting a community educational session on preventive actions that can decrease the number of motor vehicle crashes​ (MVCs) and the related mortality and morbidity. Based on recent research on the​ subject, which ethnic group will the nurse focus on to provide the greatest benefit in the community in which she​ works? Whites Hispanics African Americans Native Americans

Native Americans are at an especially high risk of MVCs and are more than twice as likely to be involved in an MVC as Whites and African Americans. This is the group that the nurse will target for the educational session.

The nurse is planning care for a client who has sustained multiple injuries from a motor vehicle crash. The nurse notes that the client and the client's family are experiencing spiritual distress. Which action taken by the nurse would be most appropriate? Leave the client and family alone. Discuss with the family the difficulties they will experience when taking the client to the home environment. Encourage the family not to discuss the accident with the client. Offer to call the family minister.

Offer to call the family minister. Rationale: When noticing a client or client's family in spiritual distress, it is appropriate to contact the family minister or spiritual leader. It is not appropriate to encourage the family not to discuss the accident. The family and client should be encouraged to express their feelings. For the nurse to assume and leave the client and family alone would be inappropriate as it would be more appropriate for the nurse to remain present. While it is appropriate to evaluate the needs at the home should the client be discharged, it is not appropriate to merely discuss with the family the difficulties they will face.

A nurse is preparing a community teaching presentation on prevention of abuse. Which levels of prevention should be included in the nurse​'s ​presentation? Select all that apply. Historical Parental Community Societal Individual

Parental Community Societal Individual Rationale The nurse knows that the levels of prevention should​ include: individual,​ community, societal, and parental. Historical information may be used to examine trending information but is not a level of prevention.

A student nurse is preparing a presentation regarding those who commit murder. Which​ description, that is particularly characteristic of murderers with antisocial personality​ disorders, will the student nurse include in the​ presentation? Person commits violent personal crimes to achieve a goal. Person is a gang member. Person has low rates of committing another murder. Person finds social reactions to the offenses reinforcing.

Person finds social reactions to the offenses reinforcing. Rationale Murderers with antisocial personality disorders may commit additional violent acts and find social reactions to their offenses reinforcing. Most murderers commit violent personal crimes to achieve a​ goal, such as resolving a​ dispute, winning an​ argument, or forcing an unwilling partner to have sexual intercourse. They have low rates of committing another murder because their murder was associated with a particular situation and person. Gang members are at higher risk to commit violent​ crimes, but do not necessarily have an antisocial psychiatric disorder.

The nurse is planning a care conference for a client who suffered massive injuries as the result of a motor vehicle crash​ (MVC). Which members of the health care team will the nurse invite to the care conference for this ​client? ​(Select all that​ apply.) Physical therapist Physician ​Nurse-midwife Emergency medical technician​ (EMT) Surgeon

Physical therapist Physician Surgeon Rationale Depending on the type of injuries present in the victim of an​ MVC, the following health care disciplines may need to be utilized to help diagnose and identify the extent of the client​'s ​injuries: physicians,​ surgeons, and such ancillary health care staff as physical therapists. An EMT would be involved during the initial care of the client but would not be on the continuing care team. A​ nurse-midwife would not be involved even if the client is pregnant.

The nurse is providing care to a client who has experienced a gunshot wound. During the​ assessment, the nurse notes that the client​'s blood pressure has significantly dropped and symptoms of shock are occurring. Which nursing intervention is a priority for this​ client? Prepare the client for intubation Administer a pain​ medication, per order Prepare intravenous fluid administration Update the client​'s family on the current condition

Prepare intravenous fluid administration Rationale The priority nursing intervention for a client who is experiencing shock is fluid replacement. The nurse would prepare to administer fluids to this client as this is the priority. There is no indication that the client is experiencing airway issues and requires intubation. While administering pain medication is​ important, this is not the priority for a client who is experiencing shock. The nurse will update the client​'s family on the current condition once the client is stabilized.

The nurse is caring for an elderly client who has been admitted with a recent fall. The admission assessment revealed several bruised areas on the back and legs. During the interview with the caregiver, the caregiver states, "I don't know what to do with her when I go to work during the day so I leave her home alone." What is the most appropriate action for the nurse to take? Provide resource information on adult day cares. Threaten to contact the authorities. Suggest art therapy. Encourage play therapy.

Provide resource information on adult day cares. Rationale: Providing resource information on adult day cares is most appropriate in this situation. The client's caregiver is expressing concern about leaving them home alone and an adult day care may give the caregiver a safe option for the times the caregiver is at work. Play therapy most commonly helps children play out traumatic themes, fears, and distorted beliefs. It is a nonthreatening way to process thoughts and feelings associated with the abuse, both symbolically and directly. Art therapy provides an opportunity to express feelings for which there are no words. While elder abuse is a reportable event, the lack of the caregiver's knowledge of resources has attributed to the safety issue.

The nurse who is caring for a client who was a victim of intimate partner violence​ (IPV) is aware that recovery from this type of relationship can be a long and difficult process. Which should the nurse identify as the victim​'s main goal in reconstructing her​ life? Regaining a sense of empowerment and safety Getting back into work and home routines Getting through the shock and confusion of the act Resolving grief over any losses

Regaining a sense of empowerment and safety Rationale The main goal for a victim is to regain a sense of empowerment and safety. The victim needs to move from being a victim to being a survivor. A sense of security and safety is vital to this transition. Getting back to work and home​ routines, resolving grief over any​ losses, and getting through the shock and confusion are all​ important, but not the ultimate goal.

An alert and oriented older adult client is receiving home care services following a cerebrovascular accident that has left her with​ right-sided hemiparesis. She lives with her daughter and​ son-in-law. The nurse suspects that the client is being neglected when she observes that the client​'s hair and clothes are dirty and the client smells of urine. Which nonpharmacologic treatment would be a priority for this​ client? Report the neglect to the appropriate agency Wait until enough trust has been developed to enable the client to approach the nurse first Confront the daughter with the suspicions Interview the​ son-in-law to gain his perspective on the situation

Report the neglect to the appropriate agency Rationale Reporting elder neglect to the appropriate​ agency, according to the requirements of state​ law, is a nonpharmacologic treatment of elder neglect and takes priority in this case. Developing trust is​ also, but it does not take priority in this case. The nurse should not confront the daughter or​ son-in-law but should report the suspected neglect to the proper authorities and allow them to investigate the situation.

Which nursing diagnosis would be priority for a homosexual client who has been repeatedly physically assaulted by the partner? Chronic low self-esteem related to guilt and shame for being a victim of abuse Social isolation related to control by the significant other and feelings of inadequacy Powerlessness related to feelings of dependence on significant other Risk for injury related to history of abuse by significant other

Risk for injury related to history of abuse by significant other Rationale: The safety of the client is the priority diagnosis. The greatest predictor of continued violence is the previous history of violence by the partner. Although powerlessness related to feelings of dependence on the significant other is an appropriate diagnosis, a concern for safety is the number-one priority. Chronic low self-esteem related to guilt and shame for being a victim of abuse may be appropriate for this client, but safety is the first concern. Social isolation related to control by the significant other and feelings of inadequacy may be an appropriate diagnosis for this client, but a threat to safety would supersede this diagnosis.

A high school freshman has been teased and taunted about his small size by senior class members. He has no close friends and usually sits alone when eating lunch in the cafeteria. When he fell down in physical education class, the other students laughed and called him "klutz." The school nurse should provide further teaching if the nursing student selected which nursing diagnosis for this teen? Loneliness related to rejection from peers and feelings of isolation Risk for other-directed violence related to history of violent behaviors Fear related to being taunted and humiliated by peers Self-esteem disturbance related to being teased about small size

Risk for other-directed violence related to history of violent behaviors Rationale: There are no data to support the nursing diagnosis of risk for other-directed violence related to history of violent behaviors. The student has not made any violent threats, exhibited signs of uncontrolled anger, or brandished a firearm. Loneliness related to rejection from peers and feelings of isolation is an appropriate nursing diagnosis because he lacks a sense of belonging as evidenced by his isolative behaviors. Self-esteem disturbance related to being teased about small size is an appropriate nursing diagnosis because his small frame and freshman status make him vulnerable to low self-esteem issues. Fear related to being taunted and humiliated by peers is an appropriate nursing diagnosis because his behavior indicates an inability to protect himself from bullying behavior.

Which behavior does the school nurse recognize as an indicator that a school-age child has been physically abused? The child tells other children that they will get a "time-out" if they continue to misbehave. The child sits quietly with a friend in the schoolyard instead of playing kickball. The child bullies other children and threatens them to "keep quiet about it." The child acts obediently when a parent scolds the child to be quiet.

The child bullies other children and threatens them to "keep quiet about it." Rationale: It is common for children to model the behaviors of parents, siblings, other adults, or actions they see on television. Therefore, children have a high likelihood of adopting abusive tendencies perpetrated by their parents or siblings. Acting obediently when being scolded indicates appropriate discipline by the parent. There may be many reasons why the child does not want to participate in a physical sport. An abused child may be withdrawn and isolated from peers. Nonphysical interventions such as time-outs are more effective than spanking at modifying unwanted behavior.

You are caring for Ms.​ Hernandez, a young woman who was recently raped. Ms. Hernandez is in shock and disbelief. When you try to give her antibiotics per the healthcare​ provider's order, she refuses to take them. Which is the best response to Ms.​ Hernandez's refusal to take​ medication? ​"The medication will help you forget the​ trauma." ​"It is not necessary for you to take​ medication." ​"The medication will help treat possible​ STDs." ​"The medication will prevent​ pregnancy."

The best response is to explain that the antibiotics will help treat possible sexually transmitted diseases​ (STDs). Telling Ms. Hernandez she does not need the medication would be misleading and would not provide her with information she needs to make an informed decision. The antibiotics will not help Ms. Hernandez forget the trauma that happened to her. Antibiotics do not prevent​ pregnancy; Ms. Hernandez may receive an order for emergency contraception to prevent pregnancy.

A client has sustained a chest wound as the result of a stabbing. The trauma team has inserted a chest tube to suction. What is the most appropriate goal for this​ client? The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 92%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 88%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 85%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 90%.

The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 92%. Rationale One of the appropriate client goals and outcomes for a client who is the victim of an assault or attempted homicide is that the client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 92%.

Which options indicate successful achievement of client goals and outcomes for a client who has experienced an attempted​ homicide? Select all that apply. The client​'s airway remains patent. The client has benefitted from collaborative interventions. The client​'s blood pressure and heart rate remain within normal limits. The client​'s goals and outcomes are formulated. The client verbalizes emotions and concerns.

The client​'s airway remains patent. The client​'s blood pressure and heart rate remain within normal limits. The client verbalizes emotions and concerns. Rationale Client goals and outcomes should be measurable. In​ addition, client goals and outcomes should be​ client-specific and tailored to meet the client​'s needs. Examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client who has experienced an assault or attempted homicide include the client​'s airway remains​ patent, the client​'s blood pressure and heart remain within normal​ limits, and the client verbalizes emotions and concerns. Collaborative​ interventions, such as medication​ administration, are interventions that require a primary care provider​'s order. They are not client goals or outcomes or an achievement of client goals or outcomes. The formulation of client goals and outcomes is part of the planning phase of the nursing​ process, not a client goal or outcome or an achievement of a client goal or outcome.

You are caring for Mrs.​ Xavier, a woman who is being treated for cuts and bruises to her arms and face. Mrs. Xavier reluctantly tells you that her husband caused the​ injuries, but she stresses that it was the only time he has ever hit her. While you are caring for Mrs.​ Xavier, her husband enters the room and asks her to forgive him. He promises never to hurt her again and gives her a large bouquet of flowers. The nurse recognizes this act as​ what? Extremely​ confusing, considering he just abused her and is now being so kind An attempt by the husband to continue controlling the client to prevent her from asking for help and to demonstrate he is​ repentant, to avoid punishment A demonstration of the​ husband's willingness to seek help and refrain from hurting his wife again A kind gesture to move toward a better future for the couple

The nurse knows that this behavior is indicative of the husband continuing to control the victim to ensure she does not ask for help and to avoid punishment. It is not a gesture suggesting that he wants to seek help. It is not an indication of a better future for the couple. It is not​ confusing; this is a clear situation of abusive control.

The etiologies of interpersonal​ violence, abuse, and neglect relate to several different theories. Which explanation best describes the social learning​ theory? Some​ families, cultures, and communities value the subordination of women through power and privilege. Violence related to abuse and neglect is a learned behavior. The tendency to​ abuse, neglect, and become violent toward others is a result of genetic considerations and distortion in neurotransmitters. The cause of violence lies in the personality of the individual who commits abuse.

Violence related to abuse and neglect is a learned behavior. Rationale Social learning theory suggests that violence related to abuse and neglect is a learned behavior. Violent individuals are conditioned to respond aggressively and violently. Neurobiologic theory suggests that the tendency to​ abuse, neglect, and become violent toward others is a result of genetic considerations and distortion in neurotransmitters. Interpersonal theory suggests that the cause of violence lies in the personality of the individual who commits​ abuse; the perpetrator uses violence to control his anger.​ Gender-bias theory proposes that some​ families, cultures, and communities value the subordination of women through power and privilege.

You are assessing​ Marcus, a child whose teacher suspects he is the victim of abuse or neglect. Your physical assessment of Marcus reveals no unexplained or untreated​ injuries, and Marcus does not appear to be malnourished or dehydrated. Which clinical manifestation would indicate to you that Marcus might be the victim of abuse or​ neglect? He is friendly with strangers. He tells you he​ doesn't like going to the doctor. He repeatedly bites his nails. He has a bandage over a scrape on his knee.

​Marcus's repetitive habit of biting his nails may be a clinical manifestation of interpersonal abuse and neglect. Other repetitive habits in children that may be clinical manifestations of interpersonal abuse and neglect include thumb​ sucking, hair​ twisting, or rocking back and forth.​ Marcus's friendliness with strangers would not be considered a manifestation of​ abuse; rather, a child who is being abused might cry when approached by strangers.​ Marcus's aversion to going to the doctor would also not be considered an indication that he is being abused or neglected. The bandage over a scrape on​ Marcus's knee indicates that Marcus is being cared for when he has an​ injury, and​ thus, it would not be considered a manifestation of abuse or neglect.

A client who is a victim of intimate partner abuse attends a group therapy session. Which comment by the client indicates a desired outcome? "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." "I should have kept my mouth shut and none of this would have happened." "I can't leave the situation. There is nowhere for me to go." "I am not afraid to be alone with my significant other even though he is the reason I am here."

"I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." Rationale: The client is demonstrating a desired outcome by stating, "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." The desired goal is for the client to verbalize awareness that they are not responsible for the abuse and that they do not deserve it. The other responses demonstrate negative outcomes. Desired outcomes would include the client openly communicating fears in regards to the abuse and demonstrating knowledge of available resources to those in abusive situations.

A client who is a victim of elder abuse has been attending counseling sessions with their family. The nurse evaluates that an abusive family member has learned positive coping skills when which statement is made? "I am sorry for the abuse; it won't happen again." "I will need to change my behavior when my parent moves in with us." "Now that I know what my resources are, I think I can do a better job of caring for my parent." "I will make sure that my parent's needs are met."

"Now that I know what my resources are, I think I can do a better job of caring for my parent." Rationale: Elder abuse can occur when family are expected to care for the aging parent. This causes frustration, overextension, and sometimes is a financial burden. Stating that the abuser will use assistance from resources is a positive action toward behavior change. Stating that they will meet the needs of the client, that they are sorry, or that they need to change behavior are not demonstration of a positive change; it is simply lip service and a hallmark response by habitual abusers.

A 63-year-old client with Alzheimer disease is brought to the emergency department (ED) with pressure sores and severe dehydration. Upon further assessment, the nurse notices bruises on the client's neck, arms, and legs. Which question could the nurse ask the client's spouse? "Have you considered placing your spouse in a nursing home?" "How long do you leave your spouse at home alone?" "What kind of support do you have at home to care for your spouse?" "How often do you turn your spouse while your spouse is in bed?"

"What kind of support do you have at home to care for your spouse?" Rationale: Asking about support at home will assess the support system and ability of the spouse to care for the client in a safe manner. This question also indicates that the nurse is aware of possible stress on the caregiver without accusing the spouse of abuse. Asking about placing the client in a nursing home subtly implies the spouse is abusing the client and is unable to care for the client properly. The nurse first assesses the client before planning interventions. Asking about turning the client in bed does not assess the possibility of caregiver strain nor does it offer support to the caregiver. Asking about the length of time the client is alone assumes that the client's injuries are signs of neglect or abuse.

A client is admitted after sustaining a severe physical assault during a robbery. The client has blood loss and numerous severe lacerations. Which goals are most appropriate to include in the initial plan of care for the​ client? Select all that apply. Client will be free of chronic pain. Client will be free of secondary injury related to trauma. Acute pain will be less than a 2 on a scale of 0 to 10. Client will demonstrate an effective breathing pattern. Client​'s blood pressure and heart rate will remain within normal limits.

Client will be free of secondary injury related to trauma. Acute pain will be less than a 2 on a scale of 0 to 10. Client will demonstrate an effective breathing pattern. Client​'s blood pressure and heart rate will remain within normal limits. Rationale The goals that are appropriate for this client include a stable blood pressure and heart​ rate; an effective breathing​ pattern; acute pain of less than 2 on a scale of 0 to​ 10; and the client will not experience a secondary injury as a result of the initial trauma. The goal of the client to not experience chronic pain is not appropriate for a client who experiences an acute injury or assault.

An assault victim arrives at the hospital seeking treatment for several lacerations and broken bones. The nurse anticipates that in addition to requiring the care of a physician, a nurse, and orthopedic care the client may also benefit from receiving which discipline? Anger management training A cardiologist A pulmonologist Counseling and spiritual guidance

Counseling and spiritual guidance Rationale: Multidisciplinary approaches are also necessary when working with victims of assault. Depending on the injuries inquired different disciplines may be required. Victims may require counseling and spiritual guidance. There is no reason that indicates that this victim needs anger management and at this time there is no indication that this victim would require a cardiologist or pulmonologist.

A client who has increased ICP has been prescribed mannitol (osmitrol) IV. For which of the following side effects should the nurse monitor. Hyperglycemia Hyponatremia Hypervolemia Oliguria

Hyponatremia Rationale: mannitol is a powerful osmotic diuretics it carries the risk of fluid and electrolyte imbalances such as hyponatremia. Hyperglycemia is not a side effect of mannitol. Hypovolemia and polyuria are side effects as opposed to hypervolemia and oliguria.

A client who has a closed head injury has had ICP readings that ranged between 16-22 mmHg for the past two days. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? Select all that apply. Suction endotracheal tube using a closed system Hyperventilate the client Elevate the clients head using 2 pillows Administer a stool softener Keep the client well hydrated

Hyperventilate the client Administer a stool softener Rationale: hyperventilation of the client will prevent hypercarbia which can cause vasodilation with a secondary increase in ICP. Administration of a stool softener will also decrease the need to bear down (valsalva maneuver) during bowel movements, which can increase ICP. Hyper flexion of the clients neck with pillows and overhydration all carry the risk of increasing ICP and should be avoided. Suctioning also increases ICP and should be done only when indicated.

A client is admitted to the emergency department with a head injury following a motor vehicle crash​ (MVC). Which nursing action is priority for this​ client? Monitoring for lower back pain Determining the presence of a fractured jaw Maintaining cervical spine precautions Establishing IV access

Maintaining cervical spine precautions Rationale: The client with a head injury may also have a cervical spine​ injury, so cervical spine precautions must be maintained as a first priority. Checking for the presence of a fractured​ jaw, monitoring for lower back​ pain, and establishing IV access are all secondary to maintaining the cervical spine alignment so that it can be evaluated.

The nurse is providing care to a client who is the victim of a stabbing. Which initial treatment is most appropriate for this​ client? Replace blood​ loss, treat for​ shock, and repair the damage Immobilization of the area to prevent further movement of the bone and allow for healing Diagnostic tests to find the source of​ bleeding, surgery to stop the bleeding and repair injury Pain​ management, surgery to remove bullet​ and/or repair​ damage, and replacement of fluids

Replace blood​ loss, treat for​ shock, and repair the damage Rationale Appropriate clinical therapy to treat a stabbing victim includes a blood​ transfusion, treatment for​ shock, surgery to repair damage if​ needed, pain​ management, prevention of​ infection, and stitches to close minor wounds. Appropriate clinical therapy to treat a victim of a shooting includes pain​ management, surgery to remove bullet​ and/or repair​ damage, medication to treat​ infection, blood​ transfusion, and treatment for shock including treatment for potential hypothermia. Appropriate clinical therapy to treat a victim with bone fractures resulting from physical attack includes immobilization of the area to prevent further movement of the bone and allow for​ healing, nonsurgical or surgical treatment of the​ fracture, pain​ management, and physical therapy after healing. Appropriate clinical therapy to treat a victim with internal bleeding as a result of blunt force trauma includes diagnostic tests to find the source of​ bleeding, surgery to stop the bleeding and repair injury if​ necessary, and treatment for shock including treatment for hypothermia.

Which nonpharmacologic treatment is appropriate in an abuse situation involving an older​ adult? Report the situation to the proper​ agency, and provide support for the victim. Provide counseling to the person committing the abuse. Protect the client​'s privacy by not documenting the abuse. Provide counseling for the victim.

Report the situation to the proper​ agency, and provide support for the victim. Rationale The nurse has the responsibility to report elder abuse to the appropriate agency and to support the victim. Protecting the client​'s privacy by not documenting the abuse would be a violation of the nurse​'s duties. Counseling must be done by a trained professional.

Which actions are appropriate nonpharmacologic treatments of a neglected or abused​ child? Select all that apply. Reporting the abuse or neglect to the appropriate agency Family therapy for the parents Providing a safe environment for the child Pain medication for the child​'s injuries Play therapy

Reporting the abuse or neglect to the appropriate agency Family therapy for the parents Providing a safe environment for the child Play therapy Rationale Nonpharmacologic treatment for abuse and neglect includes providing a safe environment for the​ child; behavioral,​ cognitive, group, or play​ therapy; family therapy for the​ parents; reporting suspected child abuse or neglect to the appropriate​ agencies; and behavioral therapy for those who are abusing or neglecting the child. Pain medication is a pharmacologic therapy.

The nurse is conducting a presentation at a local school during a​ parent-teacher association​ (PTA) meeting regarding childhood safety. The nurse is asked a question about enhancing car safety. Which topics are appropriate for the nurse to share with the ​group? (Select all that​ apply.) Using a​ forward-facing belt-positioning booster seat for children over 40 lb. in the back seat Placing children over the age of 1 in a​ rear-facing seat Securing the car seat in the front or back seat as long as it is belted to the seat Using either the lap or shoulder belt as long as the seat feels and is secure For children 4​' 9close double quote" and​ taller, making sure that the lap belt fits low and tight across the​ lap/upper thigh area and that the shoulder belt is snug across the chest and shoulder

Using a​ forward-facing belt-positioning booster seat for children over 40 lb. in the back seat For children 4​' 9close double quote" and​ taller, making sure that the lap belt fits low and tight across the​ lap/upper thigh area and that the shoulder belt is snug across the chest and shoulder Rationale: Children over the age of 1 should be in a​ forward-facing seat.​ School-age children should be secured in a car seat in the back seat. It is okay to use a​ forward-facing belt-positioning booster seat for children over 40 lb. in the back seat. Both lap and shoulder belts should always be used. For children 4​' 9close double quote" and​ taller, make sure that the lap belt fits low and tight across the​ lap/upper thigh area and that the shoulder belt is snug across the chest and shoulder to avoid abdominal injuries.

The school nurse is assessing a​ third-grade child for symptoms of sexual abuse. Which behavioral manifestations support the possibility of sexual​ abuse? ​Enuresis, impulsivity, and decline in school performance ​Stuttering, impulsivity, and being the team leader when playing games with peers ​Thumb-sucking, isolating self from peers on​ playground, and excessive fear of strangers ​Hyperactivity, stuttering, and isolating self from peers on the playground

​Thumb-sucking, isolating self from peers on​ playground, and excessive fear of strangers Rationale Behavioral symptoms of children who have been sexually abused include regression​ (thumb-sucking would be regressive behavior in a​ third-grade child, who is 8dash-9 years of​ age), clinging​ behaviors, lack of peer​ friendship, and crying out or showing fear when approached by strangers.​ Impulsivity, hyperactivity,​ stuttering, and leadership traits are not manifestations of abuse.

The nurse is providing discharge instructions to a client who is recovering from a stab wound. Which statement from the client indicates the need for further​ instruction? "I will call my healthcare provider if my pain becomes worse." "I will stop taking my antibiotic as soon as I am no longer in pain." "I will do my leg exercises daily as instructed by my physical therapist." "I will call the healthcare provider for a​ follow-up appointment tomorrow."

"I will stop taking my antibiotic as soon as I am no longer in pain." Rationale The client will be taught to complete all antibiotics for the prescribed period of time. The client should not stop taking an antibiotic when he is feeling better. This statement requires further teaching. All the other comments from the client indicate appropriate understanding of the discharge instructions.

A nurse manager is working in the emergency department and is required to make assignments based on priority. Which clients would require priority care based on their initial assessment​ findings? Select all that apply. A client who is exhibiting violent behavior A client who is splinted for a femur fracture A client who is having difficulty breathing A client who is crying and distraught A client with a bullet wound to the abdomen

A client who is exhibiting violent behavior A client who is having difficulty breathing A client with a bullet wound to the abdomen Rationale The clients who would require priority nursing care include a client who is exhibiting violent​ behavior, a client who is having difficulty​ breathing, and the client with a bullet wound to the abdomen. These clients have specific needs that must be addressed on priority by the nursing staff. The client with a splinted fracture and a client who is crying will require nursing care but these clients are stable and not a threat to self or others.

A client is admitted with an open fracture of the tibia that resulted from a motor vehicle crash​ (MVC). Which item is the priority to ask during the nursing​ assessment? A history of tetanus immunizations The use of any antibiotics within the last 3 months Any previous injuries to the leg Whether the wound was exposed to dirt or gravel

A history of tetanus immunizations Rationale: Tetanus prevention needs to be assessed and is always indicated if the client has not been immunized or is not current on the immunization in the last 10 years. With broken skin in an unsterile​ environment, infection is the greatest risk with an open fracture. All open wounds are considered​ contaminated, so there is no need to ask whether the wound was exposed to dirt or gravel. While antibiotics may be prescribed upon​ admission, the use of antibiotics in the last month is not relevant. Prior injuries to the leg are irrelevant to infection.

The nurse is caring for Carter​ Lee, age​ 15, who is at his​ mother's home recovering from a gunshot wound that resulted from an attempted homicide by a gang. Carter is making good progress in meeting treatment goals related to the wound. His pain is​ tolerable, his wound care is​ excellent, sensation and mobility are​ increasing, and he is participating in physical and occupational​ therapy, and taking his medication as prescribed. He expresses to you that he is afraid to leave his home and that he is angry with his assailant. What is the priority home care teaching topic you would discuss with this​ client? Encourage the client to take medication as prescribed and report adverse effects. Instruct the client about wound care. Encourage the client to seek counseling for personal growth. Encourage the client to seek​ follow-up treatment, such as physical and occupational​ therapy, as ordered by the physician.

The client is doing well​ physiologically, but not psychosocially. The client is verbalizing emotions and​ concerns, which is positive.​ However, what he is expressing is fear and aggression. These are the feelings that underlie assault and homicide. In your assessment of the​ client's psychosocial​ wellbeing, it may be that he has not made the necessary changes to promote and enhance his personal​ safety, including seeking help when needed. The teaching topic that can address this issue is encouraging the client to seek counseling for personal growth. You can offer to facilitate referrals to community resources.