Lecture 26: Trauma/Violence
Client Needs: Psychosocial Integrity 8. A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."
D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-557,559-560 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy? a. Compensation c. Projection b. Somatization d. Denial
D The patient's statements reflect use of denial, an ego defense mechanism. This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape. The patient's statements do not reflect somatization, compensation, or projection. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 558 (Table 29 - 2) + learning from Chapter 15 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 5. A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should: (select all that apply) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.
B, D As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 557-558 (Box 29-1) TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group c. A women's shelter b. A mental health center d. Vocational counseling
C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537 | Page 544 (Box 28-6) TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 6. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.
C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 543 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 2. An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual c. Emotional b. Physical d. Economic
C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 538-539 TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain. c. bruises on extremities. b. repeated middle ear infections. d. diarrhea.
C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity 7. A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.
A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-557,559-560 TOP: Nursing Process: Implementation
Client Needs: Safe, Effective Care Environment 11. A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence c. Abuse of alcohol b. Loss of employment d. Poverty
A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 13. After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship
A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis
Client Needs: Psychosocial Integrity 5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused. c. have eating disorders. b. are attention seeking. d. are developmentally delayed.
A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 533 (Box 28-1) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 8. An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents b. Deficient knowledge related to interpersonal skills with parents c. Disturbed personal identity related to negative self-evaluation d. Complicated grieving related to poor academic performance
A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 28û22 | Page 23 | Page 51 (Box 28-4) TOP: Nursing Process: Diagnosis/Analysis
MULTIPLE CHOICE 1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."
A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543 | Page 546 TOP: Nursing Process: Implementation
Client Needs: Safe, Effective Care Environment 17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night
A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis
Client Needs: Safe, Effective Care Environment 19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.
A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 541-542 | Page 547-548 TOP: Nursing Process: Evaluation
Client Needs: Physiological Integrity 19. A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."
A The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 555 | Page 557 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 12. A nurse works a rape telephone hotline. Communication with potential victims should focus on: a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.
A The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 555-556 | Page 559 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 16. A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction c. A delayed reaction b. The long-term phase d. The angry stage
A The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 554-555 | Page 558 (Table 29-2) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? Select all that apply. a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever spank your children?" e. "Calling children 'stupid' injures their self-esteem."
A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 535-537 (Box 28-3) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment MULTIPLE RESPONSE 1. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care
A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 544-545 | Page 548 (Nursing Care Plan 28-1) TOP: Nursing Process: Planning
Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes
A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 3. An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply. a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer
A, B, C Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 555-556 | Page 557-558 (Box 29-1) | Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Planning
Client Needs: Psychosocial Integrity 2. A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.
A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 555-556 | Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation
Client Needs: Safe, Effective Care Environment 2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.
A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543-544 (Box 28-6) TOP: Nursing Process: Planning
Client Needs: Safe, Effective Care Environment 4. Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? Select all that apply. a. Coping mechanisms the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system
A, D, E The nurse assesses the victim's level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-558 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 17. A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should: a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.
B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 558 (Box 29-1) | Page 561 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 18. An unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party. Priority action by the nurse should focus on: a. preserving rape evidence. b. maintaining physiologic stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.
B Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiologic stability. The distracters are of lower priority than preserving physiological functioning. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 556-558 TOP: Nursing Process: Planning
Client Needs: Psychosocial Integrity 11. A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"
B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a non-therapeutic communication technique. The victim may or may not have friends who have had this experience, but it's important to talk about his feelings rather than theirs. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 553-554 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser
B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 (Table 28-3) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 16. An older adult with Alzheimer's disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Multiple caregivers c. Living in a rural area b. Alzheimer's disease d. Being part of a busy family
B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534-535 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity 14. Which situation describes consensual sex rather than rape? a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.
B Only the key describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are of legal age. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 553 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 5. An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects
B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 557-558 (Box 29-1) | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 3. After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity c. Flashbacks and dreams b. Confusion and disbelief d. Fears and phobias
B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 554 | Page 558 (Table 29-2) | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Assessment
Client Needs: Safe, Effective Care Environment 6. A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"
B Salty water is a slang/street name for GHB (γ-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 554 (Table 29-1) TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.
B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 TOP: Nursing Process: Planning
Client Needs: Safe, Effective Care Environment 14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.
B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 539 | Page 541-542 TOP: Nursing Process: Outcomes Identification
Client Needs: Safe, Effective Care Environment 18. An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.
B The patient's caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 546-547 TOP: Nursing Process: Planning
Client Needs: Safe, Effective Care Environment 15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological c. Physical b. Financial d. Sexual
C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 537 (Box 28-4) TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 10. A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."
C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 562 TOP: Nursing Process: Evaluation
Client Needs: Psychosocial Integrity 12. An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building c. Honeymoon b. Acute battering d. Stabilization
C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 2. A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak c. Moderate b. Mild d. Severe
D Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 560 (Nursing Care Plan 29-1) + learning from Chapter 15 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 9. The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.
D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556 | Page 558 | Page 561 TOP: Nursing Process: Planning/Outcomes Identification
Client Needs: Safe, Effective Care Environment 10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. c. Call the adult protective agency. b. Arrange for hospitalization. d. Document injuries with a body map.
D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 540-541 | Page 548-549 (Nursing Care Plan 28-1) TOP: Nursing Process: Implementation
Chapter 29: Sexual Assault MULTIPLE CHOICE 1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."
D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 553-554 | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 15. Before a victim of sexual assault is discharged from the emergency department, the nurse should: a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.
D Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556 | Page 558 (Box 29-1) | Page 561 TOP: Nursing Process: Implementation
Client Needs: Safe, Effective Care Environment 13. A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol) by an assailant. Which intervention has priority? Monitoring for: a. coma. c. hypotonia. b. seizures. d. respiratory depression.
D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 554 (Table 29-1) TOP: Nursing Process: Intervention
Client Needs: Psychosocial Integrity 9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships c. Socialization skills b. Work responsibilities d. Physical injuries
D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment