RON/BIO interpersonal violence

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 clients 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

Which statement by the parent supports a suspicion of child abuse for a 3 year old child admitted to the hospital with many poorly explained injuries?

I have no problems with any of my other children

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 childrens safety

An older client is treated in the emergency department for soft tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is confused and often falls down. A mini mental examination indicates that the client is oriented to person, place and time. Which action would the nurse take next?

Interview the client without the presence of family members

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

which warning sign would the nurse recognize as indicating a child may be a victim of abuse? select all that apply

the child doesn't want to be touched by anyone the child frequently visits the emergency department the child looks at the caregiver before answering any question

a client who has been sexually assaulted says, " i should have fought back". which response is the most therapeutic?

whatever action you took, it was the right action because it saved your life

A woman who is frequently physically abused says, " its my fault that my husband beats me" which response would the nurse use?

you say that it was your fault, help me understand that

Identify factors associated with an increased incidence of abuse within a family. Select all that apply

Pregnancy drug abuse sexual orientation

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

for a woman who has injuries that indicates possible abuse, list the nursing interventions in the priority order

1. assisting in the treatment of her physical injuries 2. gathering information about the current injuries 3. encouraging the client to express her feelings 4. obtaining an in depth history on the pattern of abuse 5. assessing her plans for maintaining safety 6. providing information about safe houses

Place the nursing interventions in the appropriate order to best ensure milieu safety for when a client begins to demonstrate aggressive behavior toward a visitor

1. calmly addressing the individual by name to redirect the clients attention 2. suggesting to the client, " walk with me to your room" 3. firmly stating that aggressive behavior like this cannot be tolerated because 'someone may get hurt' 4. explaining that the client will be placed in seclusion if the aggressive behavior continues 5. reassuring the client that the staff will help control the aggressiveness if the client is unable to do so

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

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

Which term describes a display of anger that is socially unacceptable?

agression

the client, who has 4 children, was charged with abusing the 2 year old son, who is in critical condition. which client behaviors would the nurse anticipate? select all that apply

denies beating the 2 year old son avoids talking about the situation exhibits an emotional nonchalance

which actions would be included in the safety plan for a woman in crisis, who is emotionally and physically abused by her husband? select all that apply

determining a safe place to go in an emergency memorizing the domestic violence hotline number

The nurse is conducting a routine assessment of primigravida client and notes bruises on the clients upper arms. When questioned, the client responds that her boyfriend was upset and hit her. Which is the priority nursing action?

developing a safety plan with the client

A 2 year old child is admitted with multiple fractures and bruises, and abuse is suspected. Which assessment finding supports the nurses suspicion? Select all that apply

difficulty consoling underdevelopment for age

which action is the priority after reassuring the husband about his wife's condition after a sexual assault?

discussing with him his own feelings about the situation

Which defense mechanism is most often used by individuals who physically abuse others?

displacement

Which defense mechanism is most often used by parents who abuse an infant or toddler?

displacement

The nurse notes bruises on the pregnant clients face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?

domestic abuse

which tertiary interventions would the nurses for a young adult who sustained injuries as a result of physical battering by her partner? select all that apply

identifying the benefits of attending a support group for battered women providing her with information regarding local domestic violence shelters

which assessment data would the nurse obtain for a woman who was sexually assaulted 2 hours ago? select all that apply

planning for future safety validating the experiences promoting access to community services

While assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. Which physical finding would confirm the nurses suspicion? Select all that apply

presence of burns from cigarettes presence of bedsores presence of unexplained bruises on the wrists

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 response would the nurse initially use when a 15 year old client tearfully states that her father has been sexually abusing her for the past 8 years?

sharing this information is a positive step in getting help

during a mugging and robbery, a client sustained minor abrasions and contusions. based on the assessment findings, which action would the nurse do first?

validate that anxiety is normal and have a family member stay with the client

which assessment data would the nurse obtain for a woman who was sexually assaulted 2 hours ago? select all that apply

verbatim statements regarding the assault signs and symptoms of physical trauma signs and symptoms of emotional trauma availability of support systems level of anxiety and coping mechanisms

Which behavior would the nurse expect to observe when speaking with a parent who is accused of physically abusing their child?

reveals the belief that their child needed to be disciplined

Which behavior would alert the nurse that a child is demonstrating outwardly focused anger or aggression in an overt manner?

scribbling on a classmates art assignment

which routine screening would the nurse perform specifically for pregnant adolescents?

sexual assault

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 parameter would be most important for the nurse to identify after physically assessing a sexually abused female who states, "I've got to talk to someone or i'll go crazy. i shouldn't have dated him"?

support system

which action would the nurse take to facilitate the first meeting between a 4 year old child hospitalized for physical abuse and their foster family?

providing the child and foster family with a private room

which action would the nurse take if abuse of a 10 year old child is suspected ?

report the suspicion to local authorities

a 2 1/2 year old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. which statements are more likely to come from a parent who engages in child abuse? select all that apply

1. trial and error is a way for kids to learn about accidents and dangers 2. every time i turn around the kid is falling over something 3. this child is adventurous and doesn't understand about getting hurt 4. the kid didn't have a problem using the stairs without my help before this 5. little kids are always on the go, and i just can't keep running after him

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

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 100mg prescribed intramuscularly (IM) stat?

The medication dose prescribed is more than the recommended amount for this client

Which questions would the nurse ask the parent of a child who is suspected of being bullied at school? select all that apply

does your child exhibit any anxiety? has your child tried to harm himself or herself? how is your childs academic performance?

which primary intervention would the nurse implement for a client who is given an as needed medication and confirmed to seclusion to protect the other clients?

evaluate the clients progress toward self control

a toddler who was physically abused is admitted to the pediatric unit. which behavior would the nurse expect when approaching the child?

exhibiting fear of physical contact initiated by anyone

while interviewing the parents of an injured child who is brought to the emergency department, the nurse begins to suspect child abuse. which parental behaviors might support this conclusion? select all that apply

focusing on the childs role in sustaining the injury changing the story of how the child sustained the injury giving an explanation of how the injury occurred that is not consistent with the injury

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 childs school performance is declining rapidly, and the child has developed poor relationships with is or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings would have led the nurses to this suspicion ?

foreign bodies in the rectum, urethra or vagina

an older client who has been taking lorazepam for several years is scheduled for a procedure that requires the client to be awake for the duration. the client has a history of violence and hypotension. which antipsychotic medication is appropriate to administer to the client during the procedure? select all that apply

haloperidol perphenazine

which response would be given by a nurse caring for a client receiving corticosteroid therapy who states, " i have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening"?

inquire about mood swings

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 important nursing action would be taken after a health care provider prescribes losartan for a client?

monitor the clients blood pressure

which statement most accurately describes women who are involved in a situation of domestic violence?

most women try to leave about six times before they are successful

Which response is the most therapeutic to give to a client who has been sexually abused and tearfully says 'I'm no good now; there's nothin to live for'?

tell me more about your feelings

the nurse is assessing a toddler and the dynamics of the childs family in which abuse is suspected. which behavior exhibited would lead the nurse to suspect abuse? select all that apply

the child cringes when approached the parents cannot explain previously healed injuries the child lies still while surveying the environment

an antipsychotic medication has been prescribed for a client with delusions who physically and verbally abuses others. Which client behavior demonstrates a therapeutic response to the medication?

the client becomes aware of the behavior and its consequences

the nurse caring for a pregnant client at 28 weeks gestation suspects intimate partner violence. which assessment supports this suspicion? select all that apply

the client has injuries to the breasts and abdomen the partner answers questions that are asked of the woman the client has visited the clinic several times in the past month

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 tenures to administer this medication

the client requests something to calm her

which risk factors are associated with adolescent suicide? select all that apply

victim of family violence dependence on alcohol, drugs, or both uncertainty related to sexual orientation repeated demonstration of poor impulse control

which question would a home care nurse ask an older adult, dependent on care provided by their adult son, who recently has become very withdrawn and has multiple bruises in various stages of healing on their arms and torso?

what can you tell me about how these bruises occurred

Which intervention is the priority when suspicion of child abuse is confirmed?

Protecting the total well being of the child

The nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurses priority during assessment?

the clients ability to cope with the situation

For clients who have risk for impending violence, list assessments in order of escalating aggression, from the lowest risk to the highest

1. increasing tension in facial expression 2. having difficulty waiting to take turns during a group project 3. pacing in the hall 4. engaging in verbal abuse toward the nurse 5. pushing another client while waiting in line to the dining room

the client with post traumatic stress disorder awakens from a nightmare and begins threatening to strangle the roommate for 'coming at me with that knife you've got hidden'. place the nursing interventions in the appropriate order to best ensure client and milieu safety

1. remove the roommate from the room 2. remain with the client until the agitation is under control 3. arrange for anti anxiety medication to be administered as prescribed 4. arrange for a private room near the nurses station 5. institute homicide precautions at night

the client appears withdrawn but calm after a sexual assault. a small laceration on her chin and contusions on her arms and legs are noted. place the following nursing interventions in the order to best address the clients immediate needs.

1. talk to her in a calm, nonjudgmental manner 2. give clear, concise explanations of care that will be provided 3. provide care for laceration and contusions 4. encourage her to express feelings related to the assault 5. advise about potential health risks and available treatments

While questioning a rape victim, the nurses discovers that the victim does not remember anything related to the assault. Which statement by the nurse is the most probable cause of the victims memory loss?

the rape victim was drugged with flunitrazepam

a client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. after surgery, the clients 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.

Verbal abusive jealous, controlling enforces rigid sex roles hypersensitive, easily insulted isolates partner from family and friends makes others responsible for their feelings

a client throws a chair and starts screaming at the other clients, who become frightened, upset, and anxious. which action would the nurse take after the agitated client is removed?

arrange a unit meeting to discuss what has just happened

which action would the nurse manager take based on the client documentation?

ask for details about interventions that the staff tried before seclusion was initiated

A student reports that his mother beat him and that he has bruises on his back and shoulders. Which initial nursing action is priority?

assessing the child for the presence of bruises

A client who has a history of a short temper and physically abusive behavior is extremely anxious at the time of admission. which nursing action is the priority?

assign a staff member to supervise the client in the admission area

which behavior would a 2 year old child with a history of physical abuse display?

be wary of physical contact imitated by anyone

A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures on other long bones in various stages of healing. Which would the nurse suspect as the cause of the fracture?

child abuse

based on the client data, which client has the greatest risk for harm to self or others?

client 1 (history of being physically and sexually abused by family member from ages 4-12 years; exhibits stress through hyperactivity)

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 staff injury? Select all that apply

contact hospital security activate security cameras lock doors into the facility

Which traits would be expected when a client is in the reorganization phase of rape trauma syndrome? Select all that apply

eating disorder fear of being alone or in a crowd

Which actions would the nurse take to assist an aggressive client in deescalating the agitated behavior? Select all that apply

encourage the client to express perceived needs avoid verbal struggles in an attempt to demonstrate authority provide the client with clear options to the unacceptable behavior explain the expected outcomes if the client is unable to control the unacceptable behavior

which long term outcome would the nurse use for a child who has conduct disorder?

has no physically aggressive episodes for 3 months

During a home visit, the nurse discovers that a child in the household has a disability has been experiencing seizures. The childs parent appears indifferent to the childs physical, emotional or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with he child. Where should the nurse direct a referral?

Child protective services

which would the nurse assess for in pregnant women who present with signs of physical abuse or neglect?

human trafficking

a client admitted for substance abuse detoxification displayed extreme anger toward their spouse. which conclusion can be drawn based on the documentation about the client below?

the nurse responded inappropriately, because the threat of harm to the spouse was unaddressed

which behaviors indicate that the crisis intervention therapy has been successful for a client who recently left her husband because of physical abuse? select all that apply

utilizes healthier coping skills describes the current situation realistically

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

Which action must the nurse take first to therapeutically relate to parents who has abused their child?

identify personal feelings about child abusers

The nurse is teaching students about possible signs of domestic abuse. Which classic characteristics of an abuser would the nurse include? Select all that apply

inability to empathize with others perception of self as "special" and deserving of special attention