ch12: abuse/violence
The nurse is assessing a female client who has been in an abusive relationship. Which client statement(s) would indicate to the nurse the reason for the client to remain in the relationship? Select all that apply. "I don't want my children to be taken from me." "I can't get a job because I never finished school." "I love our home and don't want to leave it." "I don't have any money of my own." "They tell me they will change and I believe them."
"I can't get a job because I never finished school." "I don't have any money of my own." "They tell me they will change and I believe them." "I don't want my children to be taken from me." Leaving an abusive relationship is a process that can be complex. There are reasons for a person to remain in an abusive relationship. Lacking financial resources is one reason. Another is a strong emotional and psychological tie that causes the victim to hope the behavior will change. Some are concerned about losing custody of their children if they are unable to provide for them financially. Lacking job skills that limit employment opportunities is another reason for some to stay in an abusive relationship. Loving the home environment is not an identified reason for a person to remain in an abusive relationship.
Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence? "He doesn't like it when I go out with my girlfriends." "He was so much nicer when we started dating." "His father physically abused his mother for years." "I don't know what else I can do to keep him from getting angry at me."
"I don't know what else I can do to keep him from getting angry at me." A warning sign of relationship violence is feeling that you must change your life or yourself so you won't anger him or her. The remaining statements, while troublesome, are not as clearly associated with behaviors of violence.
A nurse is preparing to gather a health history of a client. Which questions can elicit disclosure if a client has been abused? Select all that apply. "It looks like someone has hurt you. Tell me about it." "When there are arguments at home, have you ever been hurt or afraid?" "I don't believe you. Why don't you tell me the truth?" "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it." "It appears that you are distracted. Let me know when you are ready to discuss the incident."
"It looks like someone has hurt you. Tell me about it." "When there are arguments at home, have you ever been hurt or afraid?" "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it." The U.S. Preventive Service Task Force recommends routine screening to detect current or past abuse, and risk of abuse. Most survivors do not report violence to health care workers without being specifically asked about it. Survivors may be reluctant to report abuse due to shame and fear of retaliation. Asking specific abuse screening questions has been shown to increase the detection of abuse substantially. Questions should be open ended and clients may need time to disclose the abuse. Clients need to know the nurse is listening, believes them and is concerned for their safety and well-being. Asking the client about telling the nurse the truth means the nurse does not believe them. By telling the client they are distracted, the nurse is not allowing time for the victim to discuss at their own pace.
The nurse provides care to a client who presents for an initial prenatal appointment. When reviewing the client's medical record, intimate partner violence (IPV) is documented. Which client statement made during the health history interview indicates phase 1 of the cycle of violence? "My husband monitors my cell phone calls every month when the bill arrives." "My husband is happy about this pregnancy and even bought me flowers." "My husband begged me not to leave him after the last incident." "My husband has not hit me since he promised to stop drinking several months ago."
"My husband monitors my cell phone calls every month when the bill arrives." There are three phases in the cycle of violence: phase 1 is tension building, phase 2 includes the eruption of violence, and phase 3 includes remorse from the abuser. During the tension building phase, it is not uncommon for the abuser to monitor the victim's activities, including phone calls; therefore, the statement "My husband monitors my cell phone calls every month when the bill arrives." exemplifies this stage. The statements indicating that the husband begged the client not to leave after the last abusive incident and a lack of physical violence since the previous incidence both indicate phase 3 of the cycle of violence. Flowers to celebrate a pregnancy could indicate phase 3; however, the nurse should explore this statement further before making this determination.
Which type of elder abuse involves leaving an older adult and no longer providing care for the individual? Emotional Physical Neglect Abandonment
Abandonment The six types of elder abuse are physical (injury by hitting, kicking, pushing, slapping, burning, and so on); sexual (unconsented sexual act); emotional (harm of self-worth or emotional well-being); neglect (failure to meet the older adult's basic needs of shelter, food, and so on); abandonment (leaving an older adult alone and no longer providing care); and financial (illegally misusing money, property, or assets).
Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which component is critical to the success of the plan? Access to community resources for referral A quality of life assessment tool Written educational materials An intimate partner violence (IPV) counselor
Access to community resources for referral Much of the support and treatment that will be needed for women in abusive relationships is needed in the community. Having access to these resources is the most critical aspect to ensuring effective and sustainable support for women in abusive situations. An IPV counselor in the emergency department will only be available for support when there is an acute situation for which the client has come to hospital. Such a component is effective but not a long-term option to support people in abusive relationships. A quality of life assessment tool is effective for assessment, but this is only the initial part of the plan. Written educational materials are important to enhance knowledge for women in abusive situations; however, community support services are needed to ensure follow through and sustainability.
When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present? Eye, head, and skeletal injuries; swollen glands; and breaks in skin Broken bones and finger joints, bruises, scars, and eye injuries Bruises, burns, lacerations, missing teeth, and skeletal injuries Missing teeth, scars on genitalia, loose bones, broken legs, and burn marks
Bruises, burns, lacerations, missing teeth, and skeletal injuries The most common indicators of physical abuse of a child are as follows: (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.
A 27-year-old has been brought to the emergency department by emergency medical services following a violent sexual assault that took place in the parking garage of the client's building. Which task would fall most clearly within the scope of practice of a forensic nurse? Providing reassurance to the client that the care team and the police will prioritize the client's care Assisting with diagnostic tests to determine the extent of the client's injuries Collecting specimens from the client for use as evidence Asking the client to describe the perpetrator in detail and documenting the client's statement
Collecting specimens from the client for use as evidence While a forensic nurse would certainly attempt to reassure a client such as this one, a priority forensic nursing task would be collecting specimens for use as evidence. This would supersede assisting with diagnostics, which falls within the scope of any registered nurse. The police, not a nurse, would be responsible for taking the client's statement.
A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following? Violence Harassment Jealousy Fear
Harassment Stalking is a crime of harassment in which stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Rape is a crime of violence.
A nurse is working on developing a safety plan with a client who is a survivor of violence. Which aspect of the plan would the nurse address first? Recognizing the signs of danger Devising an escape route Identifying a signal to indicate that it is safe to leave Identifying a safe place to hide
Recognizing the signs of danger One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.
Which provides the most appropriate example of neglect according to the definition of the term? Correcting a child in front of the entire class for copying homework Disciplining a 6-year-old child for "sassing" by putting tape on the child's mouth Criticizing a child frequently for being overweight and restricting the child's diet Rejecting a 3-year-old who cries and seek affection after falling
Rejecting a 3-year-old who cries and seek affection after falling Neglect is an act of omission that involves a failure by a parent or other adult to meet a dependent's basic needs, such as by providing appropriate emotional care. Rejecting a crying 3-year-old who seeks comfort after falling is an example of neglect. Harsh or humiliating discipline is an act of commission in which the adult actively inflicts physical or psychological harm. Attempting to improve a child's emotional or physical well-being in a misguided and harmful manner does not fit the definition of neglect.
After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply. The client and client's child are recent immigrants to the United States. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." The client is physically dependent on the client's son since losing mobility. The client self-describes and describes the client's child as "not well-off, but not terribly poor either."
The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." The client is physically dependent on the client's son since losing mobility. Physical and financial dependence and personality conflicts with caregivers and children are known to contribute to elder abuse. Low socioeconomic status and recent immigration are not identified as causative factors.
The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply. The client is embarrassed of the assault. The victim is responsible for the attack. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim. The person is concerned about the financial issues associated with the hospitalization.
The client is embarrassed of the assault. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim. Fewer than half of rapes and sexual assaults are reported, generally because of shame, embarrassment, concern about not being believed or fear of being blamed for the assault. Knowing the attacker may also be a factor that inhibits reporting. The majority of sexual violence is perpetrated by intimate partner or acquaintances and does nto involve weapons or severe physical violence. The perpetrator may use coercion, threats, or substances to control the victim. The nurse needs to understand these reasons to develop a therapeutic relationship to assist in the care of the client victim.
The nurse is teaching a victim of intimate partner violence how to create a safety plan. Which should be included when the nurse is assiting the client in devising an escape? Select all that apply. configure a list telephone numbers needed in case of emergency recognize signs of the perpetrator losing control don't pick a place to meet the child but improvise later prepare and hide an escape bag map the house for an escape route
configure a list telephone numbers needed in case of emergency recognize signs of the perpetrator losing control prepare and hide an escape bag map the house for an escape route One of the most important teaching goals is to help survivors develop a safety plan. When devising the plan include preparing and hiding an escape bag that includes clothes, car and house key, bank account numbers, birth certificate, insurance policies, marriage license, valuable jewelry, telephone numbers, and money. The house should be mapped for an escape route. If children are involved, a prearranged area to meet away from the house should be identified. A safety plan for a child or dependent elder might include safe places to hide and important telephone numbers, including 911 and those of the police and fire departments and other family members and friends. Recognizing signs of the perpetrator losing control is the first step of the plan which helps the victim recognize the signs of danger.
A client runs to the urgent care center because the spouse is at home drinking and waving a gun around while yelling at the children. Which action should the nurse take first? call for an ambulance for transport to the hospital assess the client for injuries call a family member to pick up the children contact the police
contact the police The client was in a lethal situation and escaped for help. Since children are in the home with an adult who is impaired with a firearm, the police should be immediately notified. There is no evidence to suggest the client is injured. The client should not return to a potentially lethal situation however the children need to be removed. The police should remove the children and not another family member since this could place them all in harm's way.
The nurse provides care to a 4-month-old infant who presents to the emergency department (ED) with the parents at the advice of the pediatrician due to poor feeding and potential dehydration. Which finding noted by the nurse during the physical examination indicates the need to assess for child abuse? sunken fontanelle ecchymosis to the arms mild diaper rash dry mucous membranes
ecchymosis to the arms Assessment is essential to determine the cause for the infant's poor feeding because infants are at a high risk for dehydration. Infants do not begin to move or ambulate on their own prior to the age of 6 months, when they begin to crawl; therefore, any bruises on an infant before the age of 6 months is cause for suspicion. Based on this information, the finding that indicates a need to assess for child abuse is ecchymosis to the arms. Although a diaper rash could be indicative of neglect, this infant's rash is mild and is not a finding that supports the need to assess for child abuse. The sunken fontanelle and dry mucous membranes support a diagnosis of dehydration, which is why the pediatrician advised the parents to report to the ED.
When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.) the client's father monitors contact with friends feeling left out of peer group has a family history of alcohol abuse must go straight home after school each day feeling social pressure to use alcohol
has a family history of alcohol abuse must go straight home after school each day the client's father monitors contact with friends Having contact with friends monitored by the father indicates there is an abuse of power and control in the home. Having to go straight home after school indicates the client is being forced into social isolation. In addition, there is a family history of alcohol abuse. These are all characteristics of violent families. Adolescents commonly report feelings of being left out and experiencing social pressures to experiment with drugs and alcohol. These are not characteristics of violent families.
A client reports being in an abusive relationship at home. Which behavior(s) would the nurse identify for the client as a sign(s) of impending danger from the client's partner? Select all that apply. increased criticism change in tone of voice increased communication use of substances indifference
increased criticism change in tone of voice use of substances Leaving or planning to leave is a dangerous time for people in violent relationships. One of the most important interventions when caring for individuals who are in an ongoing abusive relationship is to help survivors develop a safety plan. The first step in developing the plan is helping the survivor recognize the signs of danger. The use of substances, increased criticism, and a change in tone of voice may indicate that the perpetrator is losing control. Indifference and increased communication are not identified as signs of danger in an abusive relationship.
When assessing a 6-year-old child believed to be a victim of emotional abuse, the possibility is supported when the child is ... observed to be anxious and rejecting adult attention. showing signs of developmental delays. attending day care 5 days a week. parented by a single parent.
observed to be anxious and rejecting adult attention. While anxiety can be a sign of many different problems, an anxious child who rejects the attention of an adult may raise a red flag encouraging the nurse to assess further and possibly making a report. Developmental delays are not necessarily an indicator of emotional abuse, nor is attending day care on a regular basis. Being raised by a single parent is also not necessarily an indicator of emotional abuse.c
A client arrives for a follow-up appointment to receive the results of laboratory tests. For which result would the nurse take the opportunity to assess the client for intimate partner violence (IPV)? normal blood glucose level low red blood cell count positive pregnancy test low serum calcium level
positive pregnancy test Violence sometimes begins or escalates when a pregnancy occurs. Abuse during pregnancy is a significant risk factor for several fetal and maternal complications, including miscarriages, low birth weight, low maternal weight gain, infections, and anemia. Pregnancy is a window of opportunity for health care providers to screen women for intimate partner violence and refer them to the appropriate services. A low calcium level is not an indicator for IPV. A low red blood cell is associated with anemia that can occur during pregnancy; however, it is not an indication of IPV. A normal blood glucose level is not associated with IPV.
A client who experienced intimate partner violence (IPV) has had a complete physical examination with collecting of specimens. Which area would the nurse make a priority next? fear long-term effects safety risk for sexually transmitted infections (STIs)
safety Once physiologic stability is established, the nurse should determine whether the survivor is in danger for their life, either from homicide or suicide, and, if children or other dependents are in the home, whether they are in danger. Trauma may trigger suicidal ideation or exacerbate preexisting mental health conditions that place the survivor at risk. Fear may cause the client to remain in the relationship; however, this is not the priority. Long-term effects and risk for STIs are not areas that the nurse would make an immediate priority when caring for a victim of IPV.
Which child has the greatest risk for being the target of bullying at school? the child who recently immigrated to America the child who just transferred to the school the child who wears hearing aids the child who is short for his or her age
the child who wears hearing aids Children with special physical health-care needs are bullied more often, and children with a chronic emotional, behavioral, or developmental problem are more likely to be a victim of bullying. While any child may be a target for bullying, none on the other children have the obvious risk factor that a special needs child brings about.
A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer? "I don't believe that's true but even if it were it doesn't excuse the real rapes that occur." "Actually, fewer than 2% of all reported rapes are found to be false." "If a man is falsely accused, the woman is prosecuted by the law." "I'm not sure where you heard that but statistically it isn't true."
"Actually, fewer than 2% of all reported rapes are found to be false." Rape is an underreported crime due to feelings of guilt on the part of the victim. Only approximately 2% of all reported rape cases are false.
A client in an abusive relationship reports planning to leave the home the next time the partner is at work. Which suggestion would the nurse provide to the client? "Be careful because the time of leaving is the greatest risk." "That's a good time to leave." "Write down the day and time that you leave." "Make sure you have enough money."
"Be careful because the time of leaving is the greatest risk." If victims attempt to leave or actually do leave the relationship, perpetrators often escalate their violence, stalk their partners, and may even kill them, which makes leaving the time of greatest risk in an abusive relationship. For this reason, the nurse should counsel the client to be careful. Leaving the relationship when the partner is at work might not be a good time to leave. Advising to have money and writing down the day and time of leaving is not essential. The client's safety is paramount and that should be the focus of the nurse's suggestion.
A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client? "I am here to help you through every step of this process." "Relationship counseling can be very helpful." "I wonder if your perceptions of the relationship are accurate." "You have the right to be safe and respected."
"You have the right to be safe and respected." When working with someone who is a victim of partner abuse, it is important that the nurse assertively support the client's decision. The affirmation of the client's decision can help to improve the client's self-confidence as she begin the process of leaving her partner. It is important the nurse refrain from recommending couple's counseling or imply doubt about the client's situation. The nurse will likely not be involved in every step of the client's process of leaving the relationship, as the client will use a variety of resources outside the nurse-client relationship, nor should the nurse take charge and do everything for the client or imply that this will happen.
What percentage of women can expect to be a victim of an ongoing unwanted pursuit from stalking? 50-60% 40-48% 5-10% 12-32%
12-32% Women are 12-32% and men 17% who can expect to be victims of ongoing unwanted pursuit.
Approximately what percentage of women rape victims are raped by someone they know? 55% 65% 45% 35%
65% Approximately two-thirds of women are raped by people they know, including spouses, boyfriends, friends, or acquaintances. Among young women, about 50% of rapes are date rapes.
A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply. A 3-year-old with a deep finger laceration A 15-month-old with shortness of breath after peanut ingestion A 3-month-old with a fractured femur A baby with contrecoup injuries to the brain A 6-year-old is being seen for the 5th time for a urinary tract infection
A 3-month-old with a fractured femur A baby with contrecoup injuries to the brain A 6-year-old is being seen for the 5th time for a urinary tract infection Re-occurring urinary tract infections signal the possibility of sexual abuse of the child. The nurse must assess for further signs of abuse both with parents present and without. A fracture of the femur in a 3-month-old is uncommon given the infant's age and level of development. Contrecoup injuries of the brain in a baby should generate suspicion that the baby has been shaken. A 15-month-old with an allergic reaction to a peanut ingestion and a 3-year-old with a deep finger laceration should not signal abuse to the assessor. The problems are commonly seen in the pediatric emergency room.
A nurse is aware of the high incidence of intimate partner violence (IPV) and actively seeks opportunities to screen women for IPV. Which female client represents the best opportunity for assessing for IPV? A client who expressed interest in joining a grief support group following the death of her husband A client who is currently exploring long-term care options for her elderly father A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic A client who has brought her young son to the emergency department because he fell at the playground and may have an arm fracture
A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic Women who are pregnant have frequent contact with the health care system, creating a useful opportunity for IPV screening. None of the other listed situations precludes screening, but none are as ideal as frequent appointments at a consistent setting.
Which characteristics are found in violent families? Select all that apply. Alcohol use disorder Social isolation Abuse of power and control Adequate support systems
Alcohol use disorder Social isolation Abuse of power and control Abuse of power and control, alcohol use disorder, and social isolation are characteristics of violent families, as is an intergenerational transmission process. Adequate support systems are not a characteristic of a violent family.
A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes? Cyberstalking Jealousy Isolation Harassment
Cyberstalking.. Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Cyberstalking is the use of the Internet, e-mail, or other telecommunications technology to harass or stalk another person. The nurse should document the conversation in the nurse's notes.
A client seeks medical attention for injuries caused by intimate partner violence (IPV). Which information would the nurse provide to support open communication with the client? Select all that apply. Ensure client confidentiality. Meet in a quiet private place for the interaction. Ask for reasons the client stays in the relationship. Explain that refusing to talk about the situation will make it worse. Explain mandatory reporting requirements.
Ensure client confidentiality. Meet in a quiet private place for the interaction. Explain mandatory reporting requirements. Survivors of IPV are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality, disclosing any mandatory reporting responsibilities, and providing a quiet, private place in which to interact. Asking for reasons the client stays in the relationship will place the client on the defensive and harm the nurse-client relationship. The nurse needs to understand that not everyone is going to be willing to talk about the situation. Explaining that refusing to talk about the situation will make it worse is threatening to the client and may cause the nurse-client relationship harm.
A nurse is gathering information about a health history of a person who has experienced violence. Which are important caring behaviors a nurse should implement during the interview? Select all that apply. Discuss the nurse's personal feelings on victims of violence. Ask questions regarding religious background and preference. Establish trustworthiness. Maintain a nonjudgmental attitude. Secure open communication.
Establish trustworthiness. Maintain a nonjudgmental attitude. Secure open communication. Establishing a trusting nurse-client relationship is one of the most important steps in caring for any person experiencing violence. Survivors are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality and providing a quiet, private place to which to interact. The nurse must continually monitor personal feelings toward the perpetrator and survivor, especially in cases of child abuse or in situations where the person decides to remain in an abusive relationship. Seeking value clarification by the nurse may prevent negative feelings from influencing the nurse-client relationship that could lead to a nontherapeutic interaction and perhaps re-traumatize the survivor. The nurse should not ask about religious background or disclose personal feelings about the victim.
Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why? Nurses can learn from the experiences of clients and thus help prevent becoming victims of assault themselves. The attitudes of individual nurses reflect on the overall profession. Giving back the survivor as much control as possible is important. Nurses need to be able to sympathize with their clients.
Giving back the survivor as much control as possible is important. Knowing how to recognize when personal feelings are likely to interfere with optimal care is part of the nurse's professional responsibility. Giving back the survivor as much control possible is important by allowing the client to make decisions about who to call, what to do next, and what the client would like done in relation to the crime. The nurse's role in helping the survivor regain control is an essential part of recovery.
A frightened young woman calls the emergency department and tearfully tells the nurse, "I've been raped! Please help me!" Before telling the client what to do, the nurse would need to know if If the client knew her assailant, knew her location, and had notified the police If she had bathed, douched, or changed clothes If she has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility If the client was injured, was in a safe place, and had transportation available
If the client was injured, was in a safe place, and had transportation available If the client is injured, she may need immediate medical attention; if she is in a safe place, she can talk to the nurse on the phone. All other questions can wait until the client's safety is ensured.
A nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff? Importance of measuring the clients' progress in small steps Identification of consequences from changes made by survivors as minimal Encouragement for staff discussion about specific clients to gain support Expectation that survivors will accept change right away
Importance of measuring the clients' progress in small steps Nurses must become accustomed to measuring gains in small steps when working with survivors. Making any changes in significant relationships has serious consequences and can be done only when the adult survivor is ready. It is easy to become angry or discouraged with survivors, so it is important not to communicate such feelings. Discussing such feelings with other staff provides a way of dealing with them appropriately. In such discussions with supervisors or other staff, it is a must to protect the patient's confidentiality by discussing feelings around issues, not particular patients.
An 8-month-old infant has been brought to the emergency department by the infant's teenage parent. The infant is unresponsive, and after initial assessment, the care team suspects shaken baby syndrome. When providing care for this infant, the nurse should prioritize which assessment? Neurological assessment Cardiac assessment Respiratory assessment Genitourinary assessment
Neurological assessment The care team has performed sufficient assessment to suspect shaken baby syndrome rather than some other problem. While there may be musculoskeletal damage as a result of shaken baby syndrome, the most serious damage is neurological. It is neurological damage that would result in respiratory dysfunction. Cardiac and genitourinary assessments are not priorities with shaken baby syndrome.
The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply. The child reports "itching down there" There are frequent ear infections The vulva appears edematous The urinalysis reports a bacterial infection The anal area is bruised
The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection The nurse's suspicion that a child has been sexually abused is supported when the assessment data includes a bruised anal area, itching reported by the child, an edematous vulva, and a urinary infection. Ear infections are common among children.
Which is not a risk factor for child sexual abuse? The child is aged 10 years or younger. The child suffers from developmental delays. The child lives in a home where substance abuse occurs. The child has primary caretaker who is mentally ill.
The child is aged 10 years or younger. Children at high risk for sexual abuse include those who• Are aged 3 years or younger• Suffer from a developmental delay• Live in a home where substance abuse occurs• Have adolescent parents or a single parent• Are in foster care• Have primary caretakers who were sexually abused themselves• Have primary caretakers who are mentally ill or have a developmental delay
A nurse is caring for a family in which the older adult parent has been a victim of abuse and neglect by a middle-aged adult child. Which element should the nurse to keep in mind before interviewing the family? A top nursing priority would be to legally remove the adult child from the home. The nurse must allow the older adult client to decide whether to leave the situation. Placement of the older adult client in a nursing home within the community is crucial. The main focus of the nurse's actions should be on improving the older adult client's self-esteem.
The nurse must allow the older adult client to decide whether to leave the situation. 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 home or nursing home. Still, intervening in cases of older adult abuse is not a clear-cut issue. When an older adult's decision making is not impaired (competence is the legal term), they must be allowed an appropriate degree of autonomy in deciding how to manage the problem, even if the choice is to remain in the abusive situation. Forcing someone to do something against their wishes is in itself a form of victimization and denies autonomous decision making.
The nurse is assisting in the creation of a batterer intervention program (BIP) for a mental health facility. Which component(s) would the nurse ensure are included in the program? Select all that apply. sociocultural factors accepting responsibility personal history of trauma alternatives to violent behavior understanding the definition of abuse
accepting responsibility understanding the definition of abuse alternatives to violent behavior In cases of IPV, offenders are often court-ordered to engage in batterer intervention programs (BIPs) with the goal of preventing further violence. Components of treatment include accepting responsibility, alternatives to violent behavior, and understanding the definition of abuse. Most BIPs do not include information about sociocultural factors or focus on the batterer's personal history of trauma.
The nurse provides care for a client who reports intimate partner violence (IPV). Which intervention does the nurse include in the client's plan of care to address safety planning? teaching about sleep hygiene techniques initiating the paperwork required for a guardianship providing the client with supplies to treat physical injuries educating about perpetrator about behaviors indicative of losing control
educating about perpetrator about behaviors indicative of losing control Safety planning includes providing education to the client regarding manifestations that are indicative that the perpetrator is losing control. Teaching about sleep hygiene is an intervention that promotes healthy daily activity. Guardianship paperwork may be necessary for older adult or children who are survivors of abuse; however, this is not appropriate based on the current client data. Providing the client with supplies needed to treat injuries addresses the client's physical health.
The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse? sexual physical neglect psychological
neglect Neglect, in this case, is the malicious withholding of a physical necessity for this child's well-being. For this child, the neglect is intended to be punitive for bed wetting. The nurse would need to investigate further and take the necessary action in reporting this as abuse. Sexual abuse refers to sexual acts performed by an adult on a child under the age of 18. Physical abuse refers to a deliberate physical assault by an adult on the child such as burning, biting, poking, or twisting a limb. Psychological abuse refers to verbal assaults such as blaming, screaming, name-calling, and using sarcasm. Although any of these could be contributing factors to the bedwetting, there is at present no evidence that sexual, physical, or psychological abuse is occurring. Therefore, the nurse will identify that the child is being neglected.
A client who has been victimized repeatedly by a spouse is angry and verbally lashing out on the nurse. Based on the client's behavior, which technique would the nurse use with this client? provide stories about survivors of abuse instruct in relaxation techniques use "I feel" statements suggest reenacting the abuse
use "I feel" statements Anger and rage are part of the healing process for survivors and should be expected. Anger management techniques include appropriately recognizing and labeling anger and expressing it assertively. Assertive ways of expressing anger include owning the feeling by using "I feel" statements. Reenacting the abuse, relaxation techniques, and reading stories about survivors are appropriate techniques to help a child who is a victim of abuse.
A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what? 70% women and 30% men 70% men and 30% women 50% women and 50% men 90% women and 10% men
v70% women and 30% men Approximately 70% of victims killed by IPV are women and 30% are men.
