Chapter 33

17. A patient, who reported being raped 2 hours ago, provides a medical history and assessment coherently, quietly, and calmly in a monotone voice. How should the nurse assess this behavior? a. A delayed reaction to the trauma b. Indicative of ego integrity c. Evidence she is denying the rape occurred d. Employment of the defense mechanism of sublimation

ANS: A In the impact stage of trauma response, the individual might appear quite normal because the reality of the attack has not yet "registered." The emotional response might be delayed for hours or even days. The other options are not plausible. In psychology, sublimation is a mature type of defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior; denial is evidenced by a complete rejection that the event ever occurred. Ego integrity would indicate the client has accepted the event and moved on with life.

11. The nurse is preparing a care plan for a client who experienced abuse by a domestic partner. It is most important to include a long-term outcome that addresses what client need? a. Moving from the individual from victim to survivor status b. Providing a support groups for emotional assistance c. Using empathy to establish rapport and build trust d. Shifting blame for the incident from patient to perpetrator

ANS: A Moving from victim to survivor status is a process that can go on for months to years. It involves integrating the memories of the trauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthy relationships, and improved self-esteem. The other needs can usually be met in the short term.

22. A 15-year-old patient is seen for evaluation by court order. The parents seek to have this teen declared incorrigible because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize that these behaviors often occur in adolescents who have what experience? a. Childhood sexual abuse b. Antisocial personality disorder c. Early onset schizophrenia d. Ritual physical abused

ANS: A Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in teens who are sexually abused. These behaviors are not as closely aligned with any of the other options.

4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The patient has a history of binge/purge eating disorder as well as difficulty trusting and relating to others. What is the nurse's priority intervention? a. Set limits on self-harmful behavior. b. Foster belief in and valuing of family unity. c. Confront abnormal eating patterns and self-mutilation. d. Encourage discussion of personal responsibilities associated with abuse.

ANS: A Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs of the patient. Individuation should be fostered. The victim should not be encouraged to accept any personal responsibility for the abuse. The patient is aware of the eating patterns and self-mutilation; confrontation will not build trust.

10. Which comment by the nurse would best support relationship building with a client who has experienced partner abuse? a. "It's normal to feel violated, because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I'm very worried about you. I know you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

ANS: A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship build on acceptance. None of the other options would help the patient feel accepted.

7. A male victim of gang rape comes to the emergency department. The victim is severely anxious, but the nurse will not be able to care for the patient for at least 20 minutes based on the current patient load. How can the nurse best meet the client's needs? a. Assigning a female nursing assistant to remain with the patient in a private cubicle b. Assigning a male nursing assistant to help the patient undress in a private cubicle c. Directing hospital security personnel to monitor the patient in the waiting room d. Notifying law enforcement authorities of the situation immediately

ANS: A The patient should be moved from the waiting room to a cubicle as quickly as possible. He needs the reassuring presence of a woman who can reduce the fear of further sexual abuse. Assigning a man would probably increase his anxiety to panic level. The initial priority would be to care for the patient rather than notifying law enforcement.

1. During the impact stage of response to a violent crime, which nursing interventions would be appropriate for a victim? (Select all that apply.) a. Provide physical safety. b. Use empathetic responses. c. Distract the patient with humor. d. Provide clear, simple directions. e. Support expression of feelings.

ANS: A, B, D, E Because the individual experiences disorganization during the impact stage, the nurse must provide for safety and security via use of empathy, encourage expression of feelings, and provide simple clear directions. Humor might be helpful in the reorganization stage, not the impact stage.

2. Which interventions should a nurse include in the plan of care for a woman who has been physically abused by a partner for 10 years? (Select all that apply.) a. Be objective and nonthreatening. b. Help the victim to assess strengths. c. Make referrals contingent on leaving the abuser. d. Inform the woman that marital counseling is rarely effective. e. Help the victim recognize that the perpetrator's behavior is abusive.

ANS: A, B, E An objective, nonthreatening approach builds trust. Identifying the perpetrator's behavior as abusive is honest and supports the seriousness of the behavior. Helping the victim assess strengths will be necessary if the patient is to see herself as having sufficient resources to leave the abusive relationship. The distracters are nontherapeutic. Referrals should never be offered contingently. Marital counseling should be supported, if that is what the victim chooses. It might help reduce guilt feelings when the victim leaves the relationship.

18. A mother and her two children are in the emergency department for treatment of trauma experienced when the woman's husband physically abused her and the children. What is the nurse's priority intervention? a. Conduct a detail medical history on both mother and children. b. Focus on physical safety and emotional security of mother and children. c. Discuss the mother's legal rights in this situation. d. Discuss the legal obligation to notify the Child Protection Services.

ANS: B During the impact stage, the victim is acutely aware of the danger she has just escaped. Believing that the next beating could be fatal might provide incentive to take constructive action. The nurse can assist the victim to begin to consider a plan for escape when the next beating seems imminent and can provide information about resources. The remaining options are appropriately addressed after future safety is discussed.

1. For a victim of spousal abuse, a deterrent to leaving the abusive situation are the events that occur in which stage? a. Tension building b. Honeymoon c. Processing d. Battering

ANS: B In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of the battering incident. The perpetrator promises never to repeat the battering. The events occurring in the other options would not be deterrents to leaving. The processing stage is not an actual stage in the cycle.

2. A woman who has been repeatedly abused by her partner comes to the emergency department with severe contusions. She tells the nurse, "I was almost killed me this time. I need to do something." What is the nurse's priority intervention? a. Document the woman's injuries. b. Help the patient devise a safety or escape plan. c. Encourage the patient to take independent action. d. Provide referrals contingent on the patient leaving the abuser.

ANS: B Individuals who are victims of partner abuse should have an escape plan. This is of high priority when the victim's life is endangered. Encouraging the victim to take independent action is of less help than offering concrete assistance such as providing referrals and giving emergency phone numbers. Referrals should never be contingent on leaving, which might be possible only after the victim has made use of the referral and has assistance in place. Documentation is important, but not the nurse's first action.

3. Which intervention would be most therapeutic as a nurse provides initial care for a client who was abused by their partner? a. Validate the truthfulness of the victim's comments. b. Avoid pressuring the victim or disparaging the abuser. c. Acknowledge the victim's inability to change the situation. d. Allow the partner to stay with the victim during an interview.

ANS: B Nurses should never pressure a victim to leave the abuser. The patient must make the decision without coercion. Leaving is dangerous, because it escalates the violence and might result in death. Neither should the nurse disparage the perpetrator. The victim still cares about the batterer. The nurse should ask directly about abuse. The nurse should not suggest that the individual is unable to take constructive action. The patient should have a safe environment, without the abuser, to discuss the events. The nurse should not question the truthfulness of the victim's complaints.

19. Which assessment findings would prompt a nurse to suspect that a 15-year-old patient may be a victim of serial ritual abuse? a. Lying in a fetal position; echolalia; body rocking b. Multiple scars and burns; missing teeth; fear of being examined c. Scarred index finger; tooth enamel erosion; sores around mouth d. Acting-out behaviors; verbal aggression; arrested for grand larceny

ANS: B Scarring, burns, and missing teeth fit the picture of ritual abuse. The fear of examination relates to having to remove clothes in preparation for torture. The distracters are more consistent with schizophrenia, bulimia nervosa, and antisocial personality disorder.

15. What assessment data supports the possibility that the sexual abuse is incestual in nature? a. The abuse began when the client was 10 years old. b. The abuser was the client's uncle. c. The client's parents were aware that the abuse occurred. d. The abuse involved only fondling.

ANS: B Sexual abuse can involve anyone as the abuser, but incest refers to a family member. None of the other options sufficiently demonstrate the criteria required of incest.

5. A woman accompanied by her domestic partner is being assessed for reports of neck pain. When the nurse notes a bald spot on the client's scalp, the woman explains that she caught her hair in a door, which pulled it out and caused her neck injury. What is the nurse's best action to facilitate the assessment? a. Ask the client if she prefers her partner to stay during the examination. b. Require the partner to stay in the waiting room when the woman is examined. c. Call hospital security to have them stand by to prevent violence. d. Report the situation to local law enforcement authorities.

ANS: B The victim's explanation of being injured does not sound plausible. The nurse should suspect partner abuse. Regarding the other options, the victim and perpetrator must be separated to permit the victim the privacy to discuss what has really happened to her. It is unlikely that the perpetrator will act out when he can be observed by others. It is too early to involve the local police.

8. The nurse cares for a client who experienced a violent assault and battery attack. When considering the need to communicate with the client, what is the most therapeutic intervention? a. Discourage expression of feelings until the victim enters the recoil stage. b. Demonstrate empathetic communication techniques. c. Educate the victim about strategies to avoid attacks in the future. d. Maintain a matter-of-fact manner, and remain objective.

ANS: B Victims of violence require the nurse to provide unconditional acceptance of them as individuals, because the victim often feels guilty and engages in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and promote establishment of trust.

6. The nurse is establishing treatment goals for a person who was a victim of mind control and physical abuse. What is the initially focus goal for this individual? a. Making independent personal decisions b. Repressing emotions experienced during the abuse c. Re-establishing relationships with support persons d. Using desensitization strategies to restore equilibrium

ANS: C Relationships with family and former friends are invariably disrupted based on the victim's inability to trust. Re-establishing relationships would be the first step toward reorganization. Later, the victim will be able to make independent decisions for herself. Repression and desensitization are not the initial desirable outcomes since the client needs to work on reintegrating into the world.

13. When working with clients who have experienced rape, what should immediate care focus upon? a. Collecting evidence for legal purposes b. Notifying law enforcement to initiate a search for the rapist c. Helping the client feel both physically and emotional safe d. Documenting the victim's comments for future reference in care planning

ANS: C The focus of care is first helping the victim feel safe. Assessment questions and the physical procedures often seem as intrusive violations of privacy, and even physically threatening to an already vulnerable individual. The remaining options are best addressed after the basic need for safety and security are met.

20. A patient comes to the clinic for the fifth time in a month with vague complaints of not feeling well. The nurse notices fresh bruises on the patient's upper body. Which assessment question should take priority? a. "How much do you drink each day?" b. "Are you annoying to anyone?" c. "Did anyone hurt you?" d. "Have you fallen?"

ANS: C When the nurse suspects abuse, it is appropriate to speak directly to the issue. Two distracters are presumptuous and blaming. The other distracter offers a ready-made excuse for the bruises.

9. A nurse plans care for a client who in the recoil phase of trauma recovery. What assessment question addresses a common focus of this phase? a. "Are you having nightmares about the trauma you experienced?" b. "Does it feel like the abuse happen to someone else?" c. "Is there anyone you blame for putting you in that situation?" d. "What are your fantasies about getting revenge on your abuser?"

ANS: D In the recoil stage, emotional stress is high as the individual strives to come to terms with what has happened. Fantasies of revenge for the crime are natural during this stage. The initial reaction to a single-event trauma usually lasts a few minutes to a few days. Occasionally, the victim's reaction might include dissociative symptoms (amnesia, depersonalization, numbing, detachment), intrusive memories (nightmares, flashbacks), and severe anxiety. Disorganization may be a reaction in the impact stage. The beginning of this phase includes making sense of what happened and why ("Why me?"); attributing blame to self, others, or

16. A woman demonstrating characteristics of "battered woman syndrome" should be asked which assessment question to identify a comorbid psychological condition? a. "Have you ever been sexually abused?" b. "Have you ever been diagnosed with major depression?" c. "Would you say you experience anxiety on a regular basis?" d. "Are you aware of the condition known as posttraumatic stress disorder (PTSD)?"

ANS: D Many of the symptoms of battered woman syndrome correspond to the symptoms of PTSD; however, battered woman syndrome has additional symptoms not delineated as part of PTSD (e.g., depression, low self-esteem, self-blame, fatalism). It is not related to the other options.

12. What statement made by a client accused of sexual abuse is characteristic of the primary motivation for most rapes? a. "I was so nervous I just couldn't stop myself." b. "I know a lot of men who act the same way." c. "She wanted the sex, she just didn't want to say so." d. "She is such a tease; I needed to teach her a lesson."

ANS: D Rape is not a crime of sex, but rather a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

21. An adult in the emergency department has wrist slashes, suggesting self-mutilation. The patient's history reveals alcohol and drug abuse, binge eating, and unstable interpersonal relationships. Which history should the nurse suspect? a. Rape trauma b. Partner abuse c. Serial ritual abuse d. Childhood sexual abuse

ANS: D Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in patients who were sexually abused as children and have repressed the trauma. These behaviors are not as closely aligned with any of the distracters.

14. The emergency department triage nurse should assign to initially care for a female client who has been raped? a. Social worker with good communication skills b. Male nursing assistant who is tall and caring c. Nurse who is efficient and attentive to detail d. Soft-spoken and empathetic nurse

ANS: D The female rape victim might be frightened of or reluctant to interact with men, so a female nurse is preferable. The patient should not be made to feel hurried or pressured, but needs to feel nurtured and understood. A social worker is not necessarily trained to address the physical or emotional issues created by a rape.