Module 3 EAQ NCO - Concept 36 Interpersonal Violence
Which defense mechanism is most often used by parents who abuse an infant or toddler?
Displacement
A mother reports that her 3-year-old child fell down the stairs and sustained injuries to the right arm and leg. After observing multiple old bruises on the child's back, buttocks, and upper arms, which question would the nurse ask the child?
"Can you show me how you fell?"
A client who physically abused her son is undergoing treatment to help her control her behavior. Which statement indicates that the client has developed a safe coping method to help her deescalate?
"If I get angry at my son again, I'm going to need a pillow in the bedroom to punch."
Which response would the nurse use when a parent, suspected of child abuse, gives information that contradicts the information given by the child.
"Tell me again how your child fell down the stairs."
Which response with the nurse use when a parent, suspected of child abuse, gives information that contradicts the information given by the child?
"Tell me again, how your child fell down the stairs."
Which response is the most therapeutic to give a client who has been sexually abused and tearfully says, "I'm no good now; there's nothing to live for"?
"Tell me more about your feelings."
A woman who is frequently physically abused says, "It's my fault that my husband beats me." Which response would the nurse use?
"You say that it was your fault—help me understand that."
A woman who is frequently physically abused says, "it's my fault that my husband beats me." Which response would the nurse use?
"You say that it was your fault—help me understand that."
Which behavior is client diagnosed with histrionic personality disorder displaying when after being refused a sleeping pill, the client throws a book at the nurse?
Acting out
The nurse in a hospital skilled nursing unit witnesses a client's spouse vigorously shaking the elderly client who has dementia after the client has had an episode of incontinence. After discussing concerns with the nurse manager, to whom would the nurse report this observation?
Adult Protective Services
Which type of crisis has occurred when a sudden terrorist act causes the deaths of thousands of adults, and children and negatively affects our families, friends, communities, and the nation?
Adventitious
Which term describes a display of anger that is socially unacceptable?
Aggression
A woman accompanied by three young children says that she is seeking help in leaving her husband. He has beaten her for years and has recently started hitting the children. Which action would the nurse take first?
Arrange for a staff member to watch the children so the mother and nurse can talk
A woman accompanied by three young children says that she is seeking help in leaving her husband. He has beaten her for years and has recently started hitting the children. Which action would the nurse take first?
Arrange for a staff member to watch the children so the mother and the nurse can talk
The nurse is caring for a client in preterm labor who reports that she fell down the stairs and hit her chest and abdomen. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After obtaining vital signs, assessing the client, and interpreting the fetal monitor strip, which action would the nurse take next?
Ask the client if she feels safe at home
Which additional assessments should be conducted on an 18- year-old woman who was confused when found on the bathroom floor and her urinalysis tested positive for flunitrazepam?
Assess for signs of sexual assault
The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
Domestic abuse
The nurse is caring for a client who sustained a gunshot wound in a drive-by shooting. The client is fearful of further harm from unwanted visitors. Which safety intervention will the nurse implement to prevent client and stuff injury? Select all that apply. One, some, or all responses may be correct.
Contact hospital security Activate security cameras Lock doors into the facility
During a home visit, the nurse discovers that a child in the household who has a disability has been experiencing seizures. The child's parent appears indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. Where would the nurse direct a referral?
Child Protective Services
A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones and various stages of healing. Which would the nurse suspect as a cause of the fracture?
Child abuse
The nurse is caring for a client who sustained a gunshot would in a drive-by shooting. The client is a fearful of further harm from unwanted visitors. Which safety intervention will the nurse implement to prevent client and staff injury? Select all that apply. One, some, or all responses may be correct.
Contact hospital security Activate security cameras Lock doors into the facility
A parent is worried about the sudden behavioral changes in their child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings would have led the nurse to the suspicion?
Foreign bodies in the rectum, urethra, or vagina
Which important nursing action would be taken after a health care provider prescribes losartan for a client?
Monitor the client's blood pressure
Which important intervention would be included in the nursing care provided immediately after a sexual assault?
Obtaining the assault history from the client
Which routine screening would the nurse perform specifically for pregnant adolescents?
Sexual assualt
A client who has a history of aggressive, violent behavior becomes very angry and starts screaming at the nurse and pounding on the table. Which assessment is the priority?
Degree of control over the behavior
The nurse is conducting routine assessment of the primigravida client and notes bruises on the clients upper arms. When questioned, the client response that her boyfriend was upset and hit her. Which is the priority, nursing action?
Develop a safety plan with the client
Which defense mechanism is most often used by individuals who physically abuse others?
Displacement
Which traits would be expected when a client is in the re-organization phase of rape-trauma syndrome? Select all that apply. One, some, or all responses may be correct.
Eating disorders Fear of being alone, or in a crowd
Which mental health client would be at highest risk for assaultive behavior?
Experiences command hallucinations
Which long-term outcome would the nurse use for a child who has conduct disorder?
Has no physically aggressive episodes for 3 months
Which would the nurse assess for in pregnant women who present with signs of physical abuse or neglect?
Human trafficking
A married woman reports intermittent episodes of being beaten by her husband. Which behavior is typical of the honeymoon stage in the cycle of domestic violence?
Husband brings flowers and shows kindness
A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristics supports the suspicion?
I'll bring inconsistent stories about the injuries
Which action must the nurse take first to therapeutically relate to parents who have abused their child?
Identify personal feelings about child abusers
Which is the best room assignment for a child admitted with injuries that may be related to abuse?
In a room near the nurses' desk
A woman with five children and multiple facial injuries says, "My husband is an alcoholic, and he just beat me up." Which intervention would the nurse use?
Inquire about her and the children's safety.
Which rationale describes the reason the nurse would ask a client who has been raped to describe what happened?
It will let the client put the event in better perspective and help begin the resolution process.
Which intervention is the priority for a client who is agitated and has made unprovoked hostile verbal attacks on coworkers?
Maintaining safety
Which is the nurse's priority responsibility when abuse of an 8- year-old child is suspected?
Protecting the child from future abuse
Which intervention is the priority when suspicion of child abuse is confirmed?
Protecting the total well-being of the child
Which intervention would the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering phase of an assault cycle?
Provide the child with a quiet, low-stimulus environment
Which intervention is the most important for a young female client who was raped 3 days ago and continually talks about the trauma of being sexually assaulted?
Providing a safe environment that permits the ventilation of feelings
Which action would the nurse take if abuse of a 10-year-old child is suspected?
Report the suspicion to local authorities.
An 8-year-old girl visits the school nurse and reports that she no longer wants to visit her grandfather in his home because he "hugs me too tight and touches me down there" (pointing to her genitals.) She has told her parent that she does not want to spend the weekend with her grandparents, but her parent say that she has no choice. What is the most appropriate action by the nurse?
Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit
Which behavior would alert the nurse that a child is demonstrating outwardly focused anger or aggression in an overt manner?
Scribbling on a classmate's art assignment
Which intervention would the nurse use to prevent injury to others when caring for a client with intermittent explosive disorder?
Set limits and expectations Provide structure and boundaries Ignore attention-seeking behaviors
The nurse notes large welts and scars on the back of a toddler who has been admitted for an asthma attack. Which information would the nurse assess further?
Signs of child abuse
Which information is the most important to document for a female sexual assault victim?
Statement by the client about the sexual assault and the rapist
Which information is the most important to document for a female sexual assault victim?
Statements by the client about the sexual assault and the rapist
Which sign indicates a child is a victim of bullying and would be included in a teaching session for teachers?
The child asks to go to the nurses office frequently with vague complaints
The nurse is working with a child who was physically abused by a parent. Which is the most important goal for this family?
The child will live in a safe environment
A client has been robbed, beaten, and sexually assaulted. The primary health care provider prescribes 0.25 mg of alprazolam for agitation. Which event would alert the nurse to administer this medication?
The client requests something to calm her.
The nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurse's priority during assessment?
The client's ability to cope with the situation
Which conclusion would the nurse make after reviewing the prescribed medications of a battered and agitated client who experienced a street brawl and has haloperidol 100 mg prescribed intramuscularly (IM) stat?
The medication dose prescribed is more than the recommended amount for this client.
A client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. After surgery, the client's pain is not relieved by the prescribed morphine injections. Which phenomenon is the client experiencing when they fail to achieve pain relief?
Tolerance
Which behavior is an early sign of an abusive personality? Select all that apply. One, some, or all responses may be correct.
Verbal abusive Jealous, controlling Enforces rigid sex roles Hypersensitive, easily insulted Isolates partner from family and friends Makes others responsible for their feelings
Which statement describes why a skeletal survey is the preferred diagnostic tool when nonaccidental trauma is suspected in a child with a leg fracture?
The skeletal history of the current fracture and any previous healing or healed fractures are identified.