Abuse, Neglect & Violence NCLEX

A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response? 1. To decrease the victimizer's insecurity. 2. To inflict physical harm with the weapon. 3. To terrorize and subdue the victim. 4. To mirror learned family behavior patterns related to weapons.

3 ~ The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for 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, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? 1. I know that it was not my fault. 2. My boyfriend has trouble controlling his sexual urges. 3. If I don't put myself in a dating situation, I won't be at risk. 4. Next time I will think twice about wearing a sexy dress.

1 ~ The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? 1. Controlled response pattern 2. Compounded rape reaction 3. Expressed response pattern 4. Silent rape reaction

3 ~ The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

C ~ Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? 1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Have ready access to the number of a safe house for battered women.

4 ~ The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.

A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child may have been physically abused? 1. The child shrinks at the approach of adults. 2. The child begs or steals food or money. 3. The child is frequently absent from school. 4. The child is delayed in physical and emotional development.

1 ~ The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.

An older adult diagnosed with dementia lives with family and attends daycare. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and 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 more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

ANS: B The patient's child and family 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 precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

B ~ Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

Which of the following nursing diagnoses are typically appropriate for an adult survivor of incest? (SATA) 1. Low self-esteem 2. Powerlessness 3. Disturbed personal identity 4. Knowledge deficit 5. Non-adherence

1, 2 ~ An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (SATA) 1. Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. 2. Intimate partner violence is used to gain power and control over the other intimate partner. 3. Fifty-one percent of victims of intimate violence are women. 4. Women ages 25 to 34 experience the highest per capita rates of intimate violence. 5. Victims are typically young married women who are dependent housewives.

1, 2, 4 ~ Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. It is used to gain power and control over the other intimate partner. Women ages 25 to 34 experience the highest per capita rates of intimate violence. Eighty-five percent of victims of intimate violence are women. Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups. They may be married or single, housewives or business executives.

A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the client's description of the violent rape event. 3. Meet the client's self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.

2 ~ The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She states to a nurse, My father has recently moved back to town. What should the nurse suspect? 1. Possible major depressive disorder 2. Possible history of childhood incest 3. Possible histrionic personality disorder 4. Possible history of childhood physical abuse

2 ~ The nurse should suspect that this client may have a history of childhood incest. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? 1. Phase I: The tension-building phase 2. Phase II: The acute battering incident phase 3. Phase III: The honeymoon phase 4. Phase IV: The resolution and reorganization phase

3 ~ The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

Which assessment data should a school nurse recognize as a sign of physical neglect? 1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.

1 ~ The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

Order the description of the progressive phases of Walker's model of the cycle of battering? ________ This phase is the most violent and the shortest, usually lasting up to 24 hours. ________ In this phase, the man's tolerance for frustration is declining. ________ In this phase, the batterer becomes extremely loving, kind, and contrite.

2, 1, 3 ~ In her classic studies of battered women and their relationships, Walker identified a cycle of predictable behaviors that are repeated over time. The behaviors can be divided into three distinct phases that vary in time and intensity both within the same relationship and among different couples. 1. Tension building phase. In this phase, the man's tolerance for frustration is declining. 2. Acute battering incident phase. This phase is the most violent and the shortest, usually lasting up to 24 hours. 3. Honeymoon phase. In this phase, the batterer becomes extremely loving, kind, and contrite.

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response? 1. Leopards don't change their spots, and neither will he. 2. There are things you can do to prevent him from losing control. 3. Lets talk about your options so that you don't have to go home. 4. Why don't we call the police so that they can confront your husband with his behavior?

3 ~ The most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the rescuer. Imposing judgments and giving advice is non-therapeutic.

A raped client answers a nurses questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this clients responses? 1. The client may be lying about the incident. 2. The client may be experiencing a silent rape reaction. 3. The client may be demonstrating a controlled response pattern. 4. The client may be having a compounded rape reaction.

3 ~ This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.

A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? 1. The woman may be exhibiting a controlled response pattern. 2. The woman may have a history of childhood neglect. 3. The woman may be exhibiting codependent characteristics. 4. The woman may be a victim of incest.

4 ~ The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

A patient tells the nurse, "My husband is abusive most often 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 b. Loss of employment c. Abuse of alcohol 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.

An older adult diagnosed with Alzheimer disease lives with family. 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. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

A ~ Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement 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 personal feelings. Strong positive feelings lead to over-involvement with the victim.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

A ~ The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

B ~ The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

C ~ The honeymoon stage is characterized by kindly, 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 recovery stage.

A nursing instructor is developing a lesson plan to teach about domestic violence. Which information should be included? 1. Power and control are central to the dynamic of domestic violence. 2. Poor communication and social isolation are central to the dynamic of domestic violence. 3. Erratic relationships and vulnerability are central to the dynamic of domestic violence. 4. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

1 ~ The nursing instructor should include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (SATA) 1. It often takes several attempts before a woman leaves an abusive situation. 2. Substance abuse is a common factor in abusive relationships. 3. Until children reach school age, they are usually not affected by abuse between their parents. 4. Women in abusive relationships usually feel isolated and unsupported. 5. Economic factors rarely play a role in the decision to stay.

1, 2, 4 ~ When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisors most appropriate response? 1. These clients don't know life any other way, and change is not an option until they have improved insight. 2. These clients have limited cognitive skills and few vocational abilities to be able to make it on their own. 3. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. 4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

4 ~ The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.

Which behavior best demonstrates aggression? a. Stomping away from the nurses station, going to another room, and grabbing a snack from another patient. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, I felt angry when you said I could not have a second helping at lunch. d. Telling the medication nurse, I am not going to take that or any other medication you try to give me.

A ~ Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of anothers rights.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." 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 frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "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 impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to 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 provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

B ~ In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

After treatment for a detached retina, a victim of intimate partner violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partners physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

B ~ Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we cant afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

B ~ The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we cant afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

B ~ child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.

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, colic, and croup are not problems induced by violence.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. Do you drink excessively? b. Did your partner beat you? c. How did this happen to you? d. What did you do to deserve this?

C ~ Obtaining the person's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

C ~ The assessment of physical abuse is 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.

An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurses interview, the employee says, "My partner beat me, but it was because there are problems at work." What should the nurses next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

D ~ Documentation of the injuries provides a basis for possible legal intervention. The abused adult will 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.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills 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.