Ch.10 Assessing for Violence PrepU

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? A) Undiagnosed eye disease B) Need for corrective lenses C) Undiagnosed neurologic disease D) Nerve damage caused by repeated eye injuries

Nerve damage caused by repeated eye injuries Explanation: Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses.

A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action? A) "Be careful; you'll hurt the doll that way." B) "Are you playing a game from television." C) "What are the dolls doing?" D) "Nice dolls don't do that. Why are you playing that way?"

"What are the dolls doing?" Explanation: It is easy to lead children into supplying answers they think are the ones wanted. An open-ended question does not suggest an answer.

An adult female client is being assessed for intimate partner violence (IPV). She acts as if the abuse she has suffered is normal. What could be a reason for her actions? A) She has a history of violence in her family B) She does not understand what constitutes violence C) She does not want to get into trouble D) She knows if she says anything she will be abused again

She has a history of violence in her family Explanation: Some clients deny the seriousness of violence or consider it "normal." They may feel this way because many people in their family have also experienced violence or because most women or men or a specific group in their culture commonly experience it.

A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply. A) Failure to provide adequate nutrition to an elder B) Shoving an elder into a wheelchair C) Administering the wrong medication to an elder inadvertently D) Forcing an elder to perform a sexual act E) Having an elder sign financial documents without an understanding of what is being signed

-Forcing an elder to perform a sexual act -Shoving an elder into a wheelchair -Having an elder sign financial documents without an understanding of what is being signed -Failure to provide adequate nutrition to an elder Explanation: Elder mistreatment, also known as elder abuse, includes neglect (e.g., failure to provide adequate nutrition); physical abuse (e.g., shoving an elder into a wheelchair); sexual abuse (e.g., forcing an elder to perform a sexual act); financial abuse (e.g., having an elder sign financial documents without an understanding of what is being signed); psychological abuse (including humiliation, intimidation and threats; exploitation; and abandonment or prejudicial attitudes that decrease one's quality of life, and are demeaning to those over the age of 65 years. Administering the wrong medication to an elder inadvertently is a medical error but is not elder mistreatment, as it is an accident.

The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client? A) Low self-esteem B) Risk for infection C) Readiness for enhanced family relationship D) Readiness for enhanced family health management

Low self-esteem Explanation: Since the client has been admitted in the past for injuries caused by intimate partner violence, the most appropriate diagnosis would be an actual one such as Low Self-Esteem related to lack of confidence related to presence of prolonged physical, sexual, and emotional abuse. There is no evidence that the client is at risk for infection. There is no evidence that a wellness diagnosis would be appropriate for the client at this time.

The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should A) Focus exclusively on the physical examination, as elder abuse is primarily physical nature B) Mae sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication C) Ask to speak to Mr. Jenkins' son directly, to ask him candidly about the potential abuse D) Keep in mind that elder abuse is usually reported, indicating that Mr. Jenkins is not likely a victim

Make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication Explanation: A consequence of elder mistreatment is the inability to get food or medication because of neglect.

The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family? a) A top nursing priority will be to legally remove the son from the home b) The main focus of the nurse's actions should be on improving the elderly mother's self-esteem c) The nurse must allow the elderly mother to decide if she wants to leave the situation or not d) Placement for the elderly woman in nursing home within the community

The nurse must allow the elderly mother to decide if she wants to leave the situation or not Explanation: Removing children and older adults from their families or caregivers often is necessary to ensure immediate safety. If the home of an abused or neglected child or older adult cannot be made safe, the nurse must facilitate other professionals involved in placing the child or older adult in a foster or nursing home. Still, intervening in cases of elder abuse is not a clear-cut issue. When an older adult's decision making is not impaired (competence is the legal term), he or she must be allowed an appropriate degree of autonomy in deciding how to manage the problem even if he or she chooses to remain in the abusive situation. Forcing someone to do something against his or her wishes is itself a form of victimization and denies autonomous decision making.

The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation? A) "I have not seen my parents in 6 months; they live only 30 minutes away." B) "My boyfriend hits the kitchen wall with his fist just inches from my head." C) "My boyfriend says I'm stupid even though I have a degree in education." D) "If my boyfriend wants me to know something, he has the kids tell me."

"I have not seen my parents in 6 months; they live only 30 minutes away." Explanation: Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go. Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them self. A perpetrator uses children to relay messages to exert power or control the victim.

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence? A) "I will assess a client for abuse and violence only when they present with bruises or a broken limb." B) "I will assess a client for abuse and violence with every client encounter." C) "It is not necessary to assess every client. Some clients get offended when you as them those questions." D) "I will assess pregnant clients who come to the clinic."

"I will assess a client for abuse and violence with every client encounter." Explanation: Routine assessment for violence and safety is important during every encounter with clients because of the high prevalence of human violence and its short- and long-term effects on health, relationships, and well-being.

The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? A) "Is your partner being mean to you?" B) "Why do you think your husband has beaten you?" C) "It looks like someone has hurt you. Tell me about it." D) "Can you describe the person who did this to you?"

"It looks like someone has hurt you. Tell me about it." Explanation: The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize her thoughts and feelings. Asking if the partner is being mean or why the client thinks the husband has beaten her already assume that the client has been abused. Asking about the person who did this to the client would be ineffective be survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly.

A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? A) Apply ice to the bruise on the client's face to reduce swelling B) Conduct a forensic interview C) Assess the client for signs of psychological abuse D) Determined whether the boyfriend was abused as a child

Conduct a forensic interview Explanation: If a nurse discovers signs of sexual abuse, including rape, on assessing a client, the nurse should conduct a forensic interview to gather data for potential legal proceedings. The other answers are of lesser priority than conducting a forensic interview.

A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse? A) Psychological abuse B) Economic abuse C) Elder abuse D) Child abuse

Economic abuse Explanation: Economic abuse, also known as financial abuse, is the improper exploitation of another person's personal assets, properties, or funds. Examples of this type of abuse include the cashing of another person's checks without authorization or permission, forging signatures, and misusing or stealing money or possessions. Humiliating, depriving, and intimidating the victim is an example of psychological abuse. Elder mistreatment—also known as elder abuse—includes neglect and various types of abuse committed against those over the age of 65 years. Child abuse is neglect or abuse of a child under the age of 18.

Elder abuse can include A) Nursing home admission B) Economic exploitation C) Using an elder day-care sitter D) Uncontested divorce

Economic exploitation Explanation: Economic abuse may be evidenced by preventing the victim from getting or keeping a job, controlling money and limiting access to funds, spending the victim's money, and controlling knowledge of family finances. Economic abuse, also known as financial abuse, is the improper exploitation of another person's personal assets, properties, or funds. A consequences of elder mistreatment includes the inability to pay for food or medication because of financial abuse.

A nurse is assessing a boy who appears to be undernourished. She can find no signs of physical abuse. She considers whether this may be a case of child abuse. Which of the following are included in the definition of child abuse? Select all that apply. A) Neglect B) Physical abuse C) Sexual abuse D) Intimate partner violence E) Elder abuse F) Emotional abuse

Emotional abuse Neglect Sexual abuse Physical abuse Explanation: There are four broad categories of child abuse: neglect, emotional abuse, sexual abuse, and physical abuse. Intimate partner violence involves victims who are adult women and men. Elder abuse involves victims who are over the age of 65 years.

Which technique should a nurse implement when interviewing with a child who has suffered physical abuse by the father? A) Establish a reassuring environment B) Offer rewards to the child for answering C) Ask questions that can be answered as "yes" or "no" D) Ask detailed questions with a lot of information

Establish a reassuring environment Explanation: The nurse should provide a reassuring environment during the interview. The nurse should not offer rewards for answering questions. The nurse should ask open ended questions and avoid questions that can be answered as "yes" or "no." The nurse should not provide a lot of information when asking questions so that the child will provide more information when answering.

Which of the following is not a true statement about intimate partner violence? A) One in every three women worldwide is a victim of intimate partner violence at some point in her life B) Intimate partner violence is based on the abuser's need to maintain power and control over the victim C) The annual cost in the United States for intimate partner violence exceeds $4 billion for medical and health services, and over $1 billion for lost productivity D) Intimate partner violence is caused by the "victim" refusing her husband's desire for sex

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex Explanation: Intimate partner violence, as defined by the Family Violence Prevention Fund, "is a pattern of assaultive behavior and coercive behavior that may include physical injury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion," and IPV "affects millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background."

The nurse assesses a client for exposure to violence. Which question that is answered affirmative indicates that the client has been abused? Select all that apply. A) Do you feel unsafe in your home? B) Are you afraid of anyone in your home? C) Has anyone in your home ever hurt you? D) Has anyone ever threatened you in public? E) How long have you been in your relationships?

-Do you feel unsafe in your home? -Has anyone ever threatened you in public? -Are you afraid of anyone in your home? -Has anyone in your home ever hurt you? Explanation:

The nurse plans to assess a 35-year-old female client for family violence. In which order should the nurse complete the HITS assessment tool? Drag statements into the proper order.

1) How often does your partner physically hurt you? 2) How often does your partner insult or talk down to you? 3) How often does your partner threaten you with physical harm? 4) How often does your partner scream or curse at you?

Before screening a child who is suspected of being abused, the nurse should do which of the following? A) Discuss legal, mandatory reporting requirements B) Make sure that one or both of the parents are present C) Make sure a physician is present D) Have the child sign a statement verifying that everything he or she says is true

Discuss legal, mandatory reporting requirements Explanation: Prior to screening, the should discuss any legal, mandatory reporting requirements or other limits to confidentiality. Other than the nurse and the client, no one else should be present in the room during the screening. The child need not sign any kind of statement before the screening.

Which of the following are forms of psychological (emotional) abuse? Select all that apply. A) Insulting B) Humiliating C) Threatening to destroy property D) Rape E) Incest

Insulting Humiliating Threatening to destroy property Explanation: Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or in public. It can also involve actions such as destroying another's property, threatening or harming pets, controlling or monitoring spending and activities, or isolating a person from family and friends. Rape and incest are forms of sexual assault.

A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting? A) Intimidation B) Coercion C) Isolation D) Privilege

Isolation Explanation: Isolation is when someone is controlling what victims do or read, whom they see or talk to, or where they go, limiting their involvement outside of the home; it is a way of using jealousy to justify actions.

When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should A) Confine the interview to yes/no questions to keep the interview simple B) Remain calm and accepting in response to any information the client discloses C) Ask leading questions to convince the child to offer information D) Offer a reward to the child for answering for difficult questions

Remain calm and accepting in response to any information the client discloses Explanation: Remember when asking questions to allow the client to answer completely. Do not interrupt the client. Convey a concerned and nonjudgmental attitude. Show appropriate empathy.

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal? A) Increased electronic surveillance B) Reducing wage gaps between men and women C) Teaching children about healthy touch D) Teaching women about the danger of men

Teaching children about healthy touch Explanation: A health goal is to reduce maltreatment and maltreatment fatalities of children.

The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse? A) The spouse is jealous B) The spouse was trying to get the client's attention C) The client is not permitted to have contact with others D) The client was sharing too much information with the other person

The client is not permitted to have contact with others Explanation: Abusive partners often control the activities of the partner and do not allow outside friendships or significant contact with others. There is not information about the situation to determine if the spouse was jealous. Pinching is not required to get someone's attention. Since the exchange was limited in the waiting room it is unlikely that the client was sharing too much information with the other person.

What are some basic rules for nurses to follow when assessing for violence? Select all that apply. A) Perform assessment and screening only when the client is alone in a safe, private environment B) Be very client when the client talks C) Demonstrate compassion, not judgement D) Ask only specific questions E) Make sure a family member is present

-Demonstrate compassion, not judgement -Perform assessment and screening only when the client is alone in a safe private environment -Be very patient when the client talks Explanation: Nurses assessing for violence should perform assessment and screening only when the client is alone in a safe, private environment. The nurse needs to establish rapport and connection by showing interest in the client and by listening. The nurse also needs to demonstrate compassion, not judgment. The nurse needs to start with general, open-ended questions and move to specific questions later. Having a family member present is the opposite of performing assessment with the client alone.

Which of the following is true about violence against women? A) Verbal attacks by a husband are not considered violence against a wife B) Some experts purport that cultural attitudes influence violence C) Between married couples, there is no behavior that meets the criteria for rape D) Violence against women is a recent development in the United States

Some experts purport that cultural attitudes influence violence Explanation: Culture, race, ethnicity, and the economy must be considered in the evaluation for suspected family violence. One needs to conduct a cultural assessment (using assessment guidelines) before attempting to understand a client's particular case of family violence, especially for members of families of a different ethnic origin from the primary ethnic background with which the nurse is familiar.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? A) "He threw me against the wall and started punching my face." B) "He yells at me for not having dinner waiting for me when he came home." C) "He calls me stupid and incompetent, asking himself why he ever married me." D) "He tells me that he is sorry and that he will never hit me again."

"He tells me that he is sorry and that he will never hit me again." Explanation: During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again until the next time. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1 or tension building.

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence? A) Offer her a pamphlet about the local battered women's shelter B) Call her home to ask her some questions about her marriage C) Wait until she comes in a few more times to make a better assessment D) Ask, "Have you ever been physically hurt by your partner?"

Ask, "Have you ever been physically hurt by your partner?" Explanation: If violence is suspected, the nurse must used direct or indirect questions to screen for abuse. Asking the woman if she has ever been physically hurt by her partner is most appropriate. Offering her a pamphlet, calling her at home, or waiting until she returns are inappropriate and do not validate the suspicion.

The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. While observing the interaction between the husband and wife, the nurse observes the husband shaking his fist at the wife. Which type of abusive or controlling behavior did the nurse observe? A) Intimidation B) Coercion C) Emotional abuse D) Isolation

Intimidation Explanation: Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them. A perpetrator makes or carries out threats to do something to hurt victims through coercion. Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go.

A nurse suspects that a 9-year-old girl who is in the office today regarding a sprained wrist has been physically abused. The nurse would like to screen the girl for signs of abuse. The girl's father is in the examination room. What should the nurse do in this situation? A) Ask the father to leave the room so that the nurse can talk with the child in private B) Proceed with the screening with the father present C) Postpone the screening until a more opportune time D) Ask that the mother also be present for the screening

Ask the father to leave the room so that the nurse can talk with the child in private Explanation: Creating a safe and confidential environment is essential to obtain concise and valid subjective data from any client who has experienced family violence. For any client over the age of 3 years, ask screening questions in a secure, private setting with no one else present in the room. Do not screen if there are any safety concerns for you or the client. To postpone the screening could jeopardize the child's safety, so the nurse should ask the father to leave the room.