CHAPTER 9 -PREPU
While assessing a client, the nurse notes the partner answering questions for the client and clumps of hair missing from the client's head. What action will the nurse perform? a). Continue with the client's assessment. b). Take the client to the lab for a blood draw. c) Inform the partner not to answer for the client. d). Determine if the client has alopecia
Take the client to the lab for a blood draw. The nurse would immediately isolate the client to provide privacy and prevent retaliation from the partner. Taking the client to the lab will isolate the client and allow an opportunity for the nurse to ask about abuse. Missing clumps of hair and the partner answering for the client are signs of intimate partner violence.
An 11-year-old boy was raised in a home where his father beat his mother on a regular basis. Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence? a). They have higher rates of schizophrenia. b). It has little impact on child functioning. c). They are at increased risk for being abused. d). Female children are more likely to experience depression.
They are at increased risk for being abused. Children being raised in a home where they have witnessed intimate partner violence demonstrate higher levels of depression and lower levels of self-esteem; these effects are pronounced in boys especially. Children of mothers who are victims of intimate partner violence are at an increased risk for abuse. Exposure to intimate partner violence adversely affects a range of child functioning.
During a prenatal assessment, the nurse observes that the client is quiet and withdrawn. The client keeps asking if her partner can come into the examination room, because the partner does not like to be kept waiting. Which question would be most important for the nurse to ask before the partner comes into the examination room? a). "Why do you keep asking for your partner?" b). "Is something bothering you?" c). "Do you feel safe in your home?" d). "What happens when you and your partner argue?"
"Do you feel safe in your home?" Client safety is the priority. Asking if the client feels safe, before the partner is present, is important. Also, the client may be reluctant to answer this question if the partner is present. Feeling safe is a higher priority than gathering specifics about the relationship, such as what occurs when they argue. The other questions can be asked with the partner present, with the client's permission.
The nurse gave a presentation about intimate partner violence (IPV) to a local community group. The nurse determines more teaching is needed when a member makes which statement? a). "For the victim's safety, the victim has to learn to be careful to not set off the abuser." b). "I did not know that both men and women can be victims of IPV." c). "I will carefully observe my friends, family, and neighbors for signs of IPV." d). "Drugs, alcohol, and pregnancy can make IPV situations much worse."
"For the victim's safety, the victim has to learn to be careful to not set off the abuser." The nurse would provide additional teaching when a member states the victim has to learn how to not set off the abuser. The victim should not be told he or she causes the situations of abuse. Living in a state of fear of retaliation for personal actions is not appropriate. Because IPV can occur to anyone, it is appropriate to observe others for signs and assist them to seek help if possible. Violence occurs in all socioeconomic classes and all genders. Although women are victims of violence more frequently than men, the prevalence of violence among men nonetheless represents a significant public health concern. One out of every four men has experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Alcohol and drugs can make the situation worse.
The nurse is caring for a client who has been a victim of intimate partner violence (IPV) for a few years. The client states, "My partner has been so sweet to me the last few days by telling me how special I am and bringing me flowers. I believe my partner is sorry and will not do this again." How will the nurse respond? a). "It sounds like the honeymoon stage of IPV, which means your partner does not love you and will hurt you again." b). "It may seem better now, but over time, IPV typically becomes accelerated and more dangerous." c). "Your partner may love you, but staying in this relationship is not worth the risk of being abused over and over." d). "Your partner is showing caring and loving actions toward you. This could indicate progress from your partner."
"It may seem better now, but over time, IPV typically becomes accelerated and more dangerous." The cycle of IPV can cover a long period of time. IPV typically becomes accelerated over time and thus more dangerous. The client needs to know that this is normal behavior for an abuser and does not indicate love or a change. The nurse would respond with facts and not personal beliefs, such as the worth of the client's relationship. The nurse would not state the client is not loved because this could result in decreased trust and respect from the client toward the nurse.
A nurse is conducting an in-service program for a group of clinic nurses about screening for intimate partner violence. One of the participants asks the nurse, "I find it difficult to ask the woman questions about this. What's the best kind of question?" Which response by the nurse would be most appropriate? a). "Direct questions are often best since there is no room for interpretation." b). "Remember that your question is reflecting your judgment about the situation." c). "There is no one best type of question. Use the type that makes you most comfortable." d). "Indirect questions work well but may take you longer to get the answer."
"There is no one best type of question. Use the type that makes you most comfortable." To screen for intimate partner violence, nurses need to ask difficult questions in an empathetic and nonthreatening manner and remain nonjudgmental in all responses and interactions. The best question is the type of question that makes the nurse feel most comfortable. Direct and indirect questions produce the same results.
A new nurse graduate is learning how to assess clients for intimate partner violence. Which statement, made by the new graduate to a client, will require the experienced nurse to intervene? a). "Your partner seems very caring. Is he or she good to you?" b). "Lots of people are abused by their partners. Are you?" c). "Have you ever been abused by someone you care about?" d). "Does your current partner ever hit or push you?"
"Your partner seems very caring. Is he or she good to you?" Asking the client if the partner is "good" could have many meanings to the client. This will not provide insight to potential intimate partner violence. The other statements are appropriate.
The nurse is caring for a client who sustained superficial injuries while sexually assaulting the partner. Which nursing action is a priority for this client? a). Determine the condition of the client's victim. b). Refer the client to psychiatric treatment for counseling. c). Notify the local authorities of the perpetrator's location. d). Apply antibiotic ointment to the client's injuries as prescribed.
Apply antibiotic ointment to the client's injuries as prescribed. The priority action for the nurse is to care for the client's injuries. The nurse would refer the client to treatment and notify local authorities in accordance with local laws and requirements. The nurse would not look for the client's victim because that client is not in this nurse's care.
A 74-year-old client presents with depression, insomnia, and atypical chest pain. When asked about thoughts of suicide, the client states "Yes, I do think about ending all this." What will the nurse do next? a). Ask the client if he or she is being mistreated. b). Notify the health care provider. c). Perform an electrocardiography on the client. d). See how long the client has been depressed.
Ask the client if he or she is being mistreated. This client is presenting with symptoms of elder mistreatment. The nurse should determine if the client is being mistreated first to know how to properly care for the client. An electrocardiography is not needed as these are symptoms of mistreatment. It is not pertinent to know the history of the client's depression or insomnia. The nurse should know what is going on with the client prior to notifying the health care provider.
A pregnant client discloses to the nurse that she has been abused by her spouse for the past 4 years. Which action will the nurse take next? a). Assess the client for signs of intimate partner violence. b). Encourage the client to seek refuge at a gender-specific victims' shelter. c). Determine why the client has remained in an abusive relationship for 4 years. d). Perform an ultrasound to assess the fetus for any injuries.
Assess the client for signs of intimate partner violence. Pregnancy and birth are trigger points for intimate partner violence because the abuser may experience a sense of loss of control. During pregnancy, the mother and fetus take priority, and the abuser attempts to maintain or regain control by abusing the woman. The nurse would assess the client and document all indications of intimate partner violence. The nurse would notify the health care provider of findings and discuss a safety plan and provide information on resources to the client. The nurse would assess the fetus for injury after assessing the client, paying close attention to the client's abdominal and perineal areas.
A 17-year old pregnant teenager is living with her 20-year old partner in a rural area with no public transportation. The clinic nurse wants to have a visiting nurse come to the home to monitor the pregnancy, but the partner refuses, stating, "We don't need people in our house...I will make sure she gets the care she needs." At the next appointment, the nurse learns he took away the client's phone and only allows her to call her mother once a week. The nurse recognizes these behaviors as which component of intimate partner violence? a). Coercive tactics b). Physical violence c). Stalking aggression d). Emotional abuse
Coercive tactics Coercive tactics includes behaviors such as limiting social interactions and controlling behaviors. These are a recognized form of abuse, even without evidence of physical injury. Emotional abuse includes verbal assault, humiliation, intimidation, or any other treatment which may diminish the sense of identity, dignity, and self-worth of another person. Stalking aggression would be following or tracking another person's movement or activity. Physical violence results in bruises, fractures, and other injuries to the body.
Which statement is false regarding emergency contraception (EC)? a). EC works by preventing fertilization, ovulation, or implantation. b). EC is most effective if it is taken within 12 hours of rape. c). EC simply contains the same hormones that are found in birth control pills. d). EC will disrupt an established pregnancy if taken within 72 hours.
EC will disrupt an established pregnancy if taken within 72 hours. Emergency contraception will not disrupt an established pregnancy.
When implementing an intervention for a client experiencing intimate partner violence, what is the primary goal? a). The client will be able to care for oneself. b). The client will be able to stand up to the abuser. c). The client will be removed from the abusive relationship. d). The client will regain a sense of control in life.
The client will regain a sense of control in life. All goals are positive for the client, but the primary goal when working with victims of intimate partner violence is for them to regain a sense of control in their lives. Control over the victim's life is the primary way an abuser maintains domination in the relationship.
A nurse involved in presenting a community education program that focuses on rape prevention is asked, "Who is likely to commit rape?" What response made by the nurse best demonstrates an understanding of who is likely to commit rape? a). "Research has yet to provide a reliable profile of those who engage in rape." b). "The inability to effectively handle stress of daily life is a common factor among rapists." c). "People with anger management issues are at high risk for such behavior." d). "Under the right set of circumstances almost any male is capable of committing rape
"Research has yet to provide a reliable profile of those who engage in rape." Assailants, like their victims, come from all walks of life and all ethnic backgrounds; there is no typical profile. What is known is that many assailants have trouble dealing with the stresses of daily life, and are frequently "hot headed." But it is not true that all rapists present with these characteristics. There is no research to support that any male is capable of committing rape.
The nurse is caring for a client who was raped a few hours ago. The client is concerned about the possibility of having contracted a sexually transmitted infection and requests an emergency contraceptive pill to prevent pregnancy. Which action by the nurse is a priority? a). Notify the local authorities of the client's situation. b). Consult a psychologist to come speak with the client. c). Test the client for sexually transmitted infections (STIs). d). Notify the health care provider.
Notify the health care provider. The nurse would notify the health care provider to obtain a prescription for an emergency contraceptive pill for the client. This medication should be taken as soon as possible. Seeking counseling is advised, but not before taking an emergency contraceptive as the effectiveness decreases every 12 hours. The nurse can test the client for STIs at any point following the rape. Testing for some STIs, such as HIV, require testing weeks and even months later. The nurse may be required to report to authorities, depending on the area the rape occurred. The nurse would have to review local laws to determine if reporting is mandatory or the client's choice.
The nurse is planning to provide education to a female client who is a victim of sexual assault. Which statement is a priority for the nurse to include in the education? a). "You have the option of taking an emergency contraceptive pill." b). "A counselor can help you process what you have been through." c). "Sexual violence can happen to anyone at any time." d). "Someone will call you with the results of your laboratory tests."
"You have the option of taking an emergency contraceptive pill." The nurse would first inform the client of her option to take an emergency contraceptive pill as this needs to be taken within the first 12 hours after the assault to be most effective. The nurse would let the client know anyone can be a victim. The nurse would also indicate that any pending laboratory test results will be provided to the client once received by the facility and that a counselor can help the client in the healing process. However, these items are not as time-sensitive.
A nurse is working in a community hospital situated in an area with a history of grievous assaults on women, including rape. The nurse discovers that most rape victims come to the hospital but leave without seeking medical treatment. Which intervention should the nurse perform to ensure that rape victims get legal and medical aid? a). Ensure that the appropriate law enforcement agencies are apprised of the incident. b). Let them wait in waiting rooms to collect their thoughts before approaching them. c). Focus on treating them rather than on collecting evidence. d). Treat them as any other client to make them feel more comfortable.
Ensure that the appropriate law enforcement agencies are apprised of the incident. For every rape victim who turns up, the nurse should ensure that the appropriate law enforcement agencies are apprised of the incident. Victims should not be made to wait long hours in the waiting room, as they may leave if no one attends to them. Victims of rape should be treated with more sensitivity than other clients. Although the primary job of a nurse is to medically care for the rape victim, a nurse should also pay due attention to collecting evidence to substantiate the victim's claim in a court of law.
A client, accompanied by the partner, has presented to the emergency department with injuries suggestive of physical abuse. When considering client safety, what is the basis for interviewing the client privately? a). Maximizing the client's opportunity to discuss both the abuser and the violence b). Providing the optimum opening to discuss the options available to address the client's needs c). Minimizing the risk of causing abuser-triggered violence during the interview or later d). Educating the woman about the connection between the violence and her physical symptoms
Minimizing the risk of causing abuser-triggered violence during the interview or later If intimate partner violence is suspected, the nurse should immediately isolate the victim to provide privacy and to prevent potential retaliation from the abuser. Asking about abuse in front of the perpetrator may trigger an abusive episode during the interview or at home. While such privacy can provide an opportunity to discuss options, needs, and the violence in general, when considering safety, prevention of further violence has priority.
The nurse is caring for a client who was raped approximately 10 hours ago. The client states, "I do not want to have a baby by whoever did this to me." Which action will the nurse do next? a). Request the facility chaplain speak with the client. b). Notify the health care provider. c). Obtain a urine specimen for a pregnancy test. d). Continue to assess the client.
Notify the health care provider. The nurse should notify the health care provider to determine if the client can be prescribed an emergency contraceptive pill. The effectiveness of the medication decreases every 12 hours after the rape occurred; therefore, the client needs this medication as soon as possible. The nurse would then complete the assessment. The victim should seek counseling, but more information is needed to determine the client's religious preference before having a chaplain come to speak with the client. Performing a pregnancy test at this time is not indicated. The test would not be positive this soon after the event or, if the client were pregnant before the rape, the medication will not have an effect on that pregnancy.
The nurse is developing a plan of care for a client who is a victim of physical and mental abuse. Which action is most appropriate for the nurse to include in the plan? a). Permit the client to participate in the care provided. b). Provide an overview of the procedures to be done. c). Tell the client about available contraceptive medications. d). Assist the client in making decisions for care.
Permit the client to participate in the care provided. Active participation in care is critical because it promotes feelings of control. The victim should be allowed to actively participate in care and decision making. The nurse should offer step-by-step explanations of procedures to alleviate fears and to demonstrate a caring attitude; however, empowering the client with control is most important at this time to facilitate recovery. The nurse should not make decisions for the client but provide facts and allow the client to make one's own informed decisions. The client needs to be informed of contraceptives if the abuse was sexual in nature; however, empowerment is a priority, then the nurse would provide education. The client needs to take the medication within 12 hours to best prevent pregnancy.
The nurse notices the caregiver of a 6-year-old client yell at, belittle, and call the client "stupid" and "ignorant" on multiple occasions. Which action will the nurse take first? a). Inform the caregiver that child protective services will be notified. b). Document the findings in the client's medical record. c). Determine if the client wants the caregiver removed from the hospital room. d). Report the abuse to the client's health care provider.
Report the abuse to the client's health care provider. Psychological maltreatment includes acts such as verbal abuse and belittlement, acts designed to terrorize a child, and lack of nurturance or emotional availability. The nurse would report such findings to the health care provider to determine the plan of care for the client. The nurse would then document the findings. The nurse would not inform the caregiver if child protective services are notified. This could result in the caregiver leaving with the client, placing the client in additional harm. The caregiver may need to be removed from the room; however, this would not be the decision for a client who is a minor.
The nurse is caring for several woman while working at a women's clinic. Which woman is at the highest risk for intimate partner violence? a). a woman living in a homeless shelter who is seeking treatment for a STI b). a woman at 24 weeks' gestation expecting her second child c). a woman seeking information regarding birth control options d). an adolescent accompanied by her mother for a pelvic examination
a woman at 24 weeks' gestation expecting her second child Intimate partner violence (IPV), as well as other forms of abuse, is more common during pregnancy. This is likely due to the stress of the pregnancy and the life changes about to happen. The other women may be at risk for IPV, but the risk is lower because they are not pregnant.
A nurse is providing care to a older adult victim of intimate partner violence. When approaching this client, the nurse must ensure to avoid which type of behavior? a). consultative b). accepting c). nonjudgmental d). critical
critical It is very important that the nurse listen carefully and nonjudgmentally. Judging or criticizing the victim for decisions might lead to the impression that the victim deserves the abuse or is to blame. The nurse should build trust and a sense of rapport with the victim and help build the victim's confidence so he or she can take the necessary steps to leave the situation.
A nurse is caring for a client who has been admitted with an ear infection. While discussing the partner with the nurse, the client says that the lover's behavior is "threatening" and "intimidating" at times, even though the partner has not physically harmed the client. The client wants to know what emotional abuse is. Which statement best describes an example of emotional abuse? a). being overly watchful of the client's every move b). throwing objects at the client c). forcing the client to have intercourse d). destroying valued possessions or attacking pets
destroying valued possessions or attacking pets Attacking pets and destroying valued possessions are examples of emotional abuse. Observing the client's movements closely may be a sign of suspicion. Throwing objects at the client is physical abuse. Forcing the client to have intercourse against her will is an act of sexual assault.
A young female immigrant has come to the clinic for medical care. On examination, the nurse discovers she underwent female genital cutting as a young girl. The nurse recognizes this practice is primarily based on: a) punishment. b). her culture. c). her choice. d). her religion.
her culture. The exact origins of female genital cutting are not known. It is not mandated by any religion and predates both Christianity and Islam. In some cultures, it is associated with feminine beauty and often signifies a rite of passage from childhood to adulthood. FGC is performed to decrease a woman's sexual desires and to ensure her chastity until marriage and receipt of a dowry from the prospective groom. Ultimately, the reality of being ostracized by the community and the possibility of being ineligible to marry create enormous social pressure to have FGC performed, pressure that exceeds the physical and emotional damage of this practice.
The nurse is assessing a client who was a previous victim of rape. The nurse believes the client is in the integration and recovery phase following the rape. Which action will the nurse recommend to the client for continued recovery? a). returning to a normal daily routine b). joining a rape survivor group c). changing positions with current employer d). pressing formal charges against the abuser
joining a rape survivor group During the integration and recovery phase, the victim begins to feel safe and starts to trust others. The victim also may become an advocate for other rape survivors. During this time, it is appropriate for the client to join a support group for rape survivors. During the disorganization phase, the victim typically experiences shock, fear, disbelief, anger, shame, guilt, and feelings of uncleanliness. During denial, the victim appears outwardly composed and returns to work or school but refuses to discuss the assault and denies the need for counseling. At this time, the client would return to daily routines. During the reorganization phase, the victim attempts to make life adjustments by moving or changing jobs and uses emotional distancing to cope. At this time, the client may change positions or employers. The client must decide whether to file charges; this is not the nurse's choice.
The nurse is assessing a woman who underwent a female circumcision for cultural reasons when she was 9 years old. The nurse observes that the prepuce and a portion of the clitoris have been removed. The nurse identifies this as which type of female genital cutting procedure? a) type II b) type IV c) type I d) type III
type I With a type I procedure, the prepuce with or without a part or all of the clitoris is excised. With a type II procedure, the clitoris and part or all of the labia minora are excised. With a type III procedure, all or part of the external genitalia is excised and the vagina is stitched or narrowed. A type IV procedure includes the following: the clitoris or labia is pricked, pierced, or incised; the clitoris and/or labia are stretched; the clitoris and surrounding tissues are cauterized; the vaginal orifice is scraped or cut; corrosive substances are introduced into the vagina; and herbs are inserted to narrow it.
The nurse is assessing the circumstances associated with a client's suspected acquaintance rape at a party. Which is the best question for the nurse to ask? a). "Do you know the assailant well?" b). "Did the assailant express regret after the assault occurred?" c). "Did you have a prior sexual relationship with the assailant?" d). "Were alcohol and drugs available at the party?"
"Were alcohol and drugs available at the party?" Although acquaintance rape and date rape do not always involve drugs, a rapist might use alcohol or other drugs to sedate the victim. It is a felony to give an unsuspecting person a "date rape drug" with the intent of raping him or her. The other questions are irrelevant to the circumstances of the rape.
The nurse is caring for a client suspected of being a victim of human trafficking. Which question, when given priority by the nurse during the admission interview, demonstrates a need for additional training? a). "Are you working toward achieving American citizenship?" b). "Can you leave your job if you find a better one?" c). "Are you afraid of those you work for?" d). "Can you get in touch with your family easily?"
"Are you working toward achieving American citizenship?" Although human traffickers prey on undocumented or illegal aliens, the status of the immigration process is not a priority in determining a client's risk factors for such abuse. All the other questions assess for freedom, safety, and autonomy, all factors that are considered when assessing for such an abusive situation.
A nurse is interviewing a rape victim who was assaulted 6 month ago. Which questions should the nurse ask the client to know the extent of physical symptoms of posttraumatic stress disorder (PTSD)? Select all that apply. -"Do you have heart palpitations or sweating?" -"Have you felt irritable or experienced outbursts of anger?" -"Do you feel numb emotionally?" -"Are you having trouble sleeping?" -"Do you ever feel as you are reliving the event?"
-"Are you having trouble sleeping?" -"Have you felt irritable or experienced outbursts of anger?" -"Do you have heart palpitations or sweating?" -"Do you ever feel as you are reliving the event?"
A newly pregnant 19-year-old woman grew up in an abusive home, and moved in with a 22-year-old man who is displeased with her cooking and housekeeping skills. He often becomes angry and physically abusive. The pregnant client has no diploma or job, no money for birth control, and her boyfriend demands sex at his leisure without use of condoms. What is the strongest risk factor for intimate partner violence during this pregnancy? a). Unintended pregnancy b). Low socioeconomic status c). Lack of access to health care d). Prior abuse
Prior abuse The strongest predictor of abuse during pregnancy is prior abuse. For women who have been abused before, beating and violence during pregnancy are "business as usual." Unintended pregnancy, low socioeconomic status and lack of access to care are stressors, but are not the highest risk factor for intimate partner violence.
Nurses at an emergency department seek to develop a plan to help clients who are victims of intimate partner violence. Which component is critical to the success of the plan? a). a quality-of-life assessment tool b). educational materials c). avenues for referral d). an intimate partner violence (IPV) counselor
avenues for referral Nurses assume their appropriate role in the effort to screen and treat victims of intimate partner violence through simple screening and having readily available information and avenues for referral.
A nurse is caring for a transgender individual who is experiencing significant distress when trying to cope with gender identity not matching the natal sex/assigned gender. Which is the most appropriate term to use when caring for this type of client? a). gender nonconformity b). gender incongruence c). gender mismatch d). gender identity disorder e). gender dysphoria
gender dysphoria The Diagnostic and Statistical Manual of Mental Disorders previously referred to the experience of a gender identity not aligned with natal sex as "gender identity disorder." The DSM-5, which is the most recent, instead refers to "gender dysphoria," which, rather than referring to being transgendered and gender nonconformity as pathological, captures the distress caused by the mismatch between a person's natal sex/assigned gender and gender identity, as well as the interference with normal functioning caused by that distress (American Psychiatric Association, 2013). Gender mismatch, incongruence, and nonconformity are descriptive terms related to transgenders, but these terms do not include the mental health issue surrounding the situation. Many transgenders experience depression, dissatisfaction, anxiety, or agitation related to not feeling comfortable with their natal sex.
A woman arrives at the neighborhood clinic asking for care related to symptoms that include bruising, lacerations and vague reports of perineal discomfort. The nurse assesses and provides care for the client's physical condition, then questions the client. Which is the best question for the nurse to ask? a). "Physical abuse is not something you have to tolerate. Would you like me to notify the police?" b). "Your injuries suggest that you are experiencing physical and or sexual abuse. Would you like to talk about what's happening?" c). "It appears that your injuries are a result of abuse and violence. Do you feel safe at home?" d). "Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?"
"Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?" Often, after a woman is victimized, she will report physical ailments, which gives her the opportunity to visit a health care setting. Opening up the possibility for women to express themselves about their experience of abuse to a nurse sends a clear message that violence should never be tolerated and not kept hidden. Presenting the opportunity in a nonthreatening, nonjudgmental manner will encourage the woman to open up to the problem either immediately or in the future.
A nurse is caring for a client who has presented to the emergency department seeking treatment after being raped. Which statement best demonstrates the nurse's attempt to fulfill the initial nursing responsibility to this client? a). "I'm going to assess you for any physical trauma this rape has caused." b). "Tell me about the events leading up to the rape." c). "You didn't deserve this assault; I'm here to help you in any way I can." d). "You are safe here; I'm going to save any evidence to be passed on to the police.
"You didn't deserve this assault; I'm here to help you in any way I can." The nurse's role in dealing with survivors of violence is to establish rapport, open up lines of communication, apply the nursing process to assess and screen all clients in all settings, and implement and intervene as appropriate. Communicating support through a nonjudgmental attitude and telling the victim that no one deserves to be assaulted are first steps toward establishing trust and rapport. None of the other statements can be effectively implemented until therapeutic rapport has been established.
The nurse is educating women on characteristics of perpetrators of intimate partner violence. What characteristics of abusers will the nurse include in the teaching? Select all that apply. -Dominates the control in personal and social situations -Arrested twice in the last year -A history of oxycodone and diazepam use disorder -Tends to be shy and reserved in social settings -10 different employers in the past 18 months
-A history of oxycodone and diazepam use disorder -10 different employers in the past 18 months -Arrested twice in the last year -Dominates the control in personal and social situations Common characteristics of abusers include, but are not limited to substance use disorder, erratic employment, history with the judicial system, and controlling behavior. Being shy and reserved is not a characteristic of abusers.
A nurse is caring for a pregnant client and discovers signs of bruises near her neck. On questioning, the nurse learns that the bruises were caused by her spouse. The client tells the nurse that the spouse had stopped hitting her some time ago, and that this was the first time during the pregnancy that she was assaulted. The client blames herself because she admits to not paying enough attention to her spouse. Which facts about intimate partner violence during pregnancy should the nurse tell the client to convince her that the violence was not her fault? Select all that apply. -Intimate partner violence is a result of concern for the unborn child when the mother doesn't fulfill her responsibilities toward the newborn. -Intimate partner violence is a result of resentment toward the interference of the growing fetus and change in the woman's shape. -Most spouses exhibit violent reactions during pregnancy as a way of coping with the stress. -Intimate partner violence is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings. -Intimate partner violence is a result of the perception of the partner that the baby will be a competitor after he or she is born.
-Intimate partner violence is a result of resentment toward the interference of the growing fetus and change in the woman's shape. -Intimate partner violence is a result of the perception of the partner that the baby will be a competitor after he or she is born. -Intimate partner violence is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings. Some of the factors that may lead to intimate partner violence during pregnancy are resentment toward the interference of the growing fetus and change in the woman's shape, perception of the baby as a competitor once he or she is born, and insecurity and jealousy of the pregnancy and the responsibilities it brings. Concern for the child will never result in physical abuse, as the unborn child is also at risk through assault during pregnancy. Serial abusers may exhibit violent tendencies during pregnancy, and such behavior is unacceptable.
The nurse has completed an assessment and interview on a client being treated for lacerations and abrasions. What acquired data support the nurse's suspicion that the client may be a victim of human trafficking? Select all that apply. -16 years of age -female -acting fearful and submissive -presented immigration document -arrived for treatment unaccompanied
-female -16 years of age -acting fearful and submissive This client has several risk factors for such abuse: female gender, adolescent age group, and acting fearful, anxious, depressed, submissive, and/or tense. Typically, the at-risk client would not have immigration documentation papers and would be accompanied by the "sponsor" who would be very reluctant to leave the client alone with staff.
A woman is being cared for in the emergency department following a sexual assault. In addition to the physical exam and collection of the rape kit, what sexually transmitted infection (STI) testing should the nurse prepare to collect during the initial examination visit? a). Syphilis, HIV, chlamydia, and herpes simplex b). HIV, hepatitis B, chlamydia, and human papillomavirus c). HIV, hepatitis C, hepatitis A, and gonorrhea d). Chlamydia, trichomoniasis, gonorrhea and hepatitis B
Chlamydia, trichomoniasis, gonorrhea and hepatitis B When testing for STIs following a sexual assault the following tests should be done: chlamydia, gonorrhea, trichomoniasis, syphilis, HIV and hepatitis B. These should also be rechecked 1 to 2 weeks after the assault. HIV testing includes three different test times after the assault. Checking for human papillomavirus should be done as a visual examination for warts 1 to 2 months after a sexual assault. Hepatitis C testing is not done routinely after a sexual assault, nor is testing for the herpes simplex virus.
The nurse is conducting a class on rape prevention for a group of young adults and is describing the various types of date rape drugs. Which drug would the nurse describe as causing a separation in perception and sensation? a) ketamine b). rohypnol c). gamma hydroxybutyrate (GHB) d). diazepam
ketamine Ketamine acts on the central nervous system to separate perception and sensation. Rohypnol produces memory loss for up to 8 hours. GHB produces euphoria, an out-of-body high, sleepiness, increased sex drive, and memory loss. It may cause unconsciousness, depression, and coma. Diazepam is an antianxiety agent that causes sedation, lethargy, mild drowsiness, confusion, and disorientation.
Which statement made by a new nurse demonstrates an understanding of the prevalence of sexual assault and related violence among the population? a). "I've come to realize that I need to include questions related to sexual assault and related violence into the assessment of all my clients." b). "The vast majority of victims of sexual assault and related violence are seen in the emergency room when they seek treatment." c). "The greatest need for thorough assessment regarding sexual assault and related violence is among those who are dependent and rely on the care of others." d). "It seems obvious that the greatest number of clients experiencing sexual abuse and related violence are the young and middle-aged adults."
"I've come to realize that I need to include questions related to sexual assault and related violence into the assessment of all my clients." Nurses will come in contact with sexual assault and related violence no matter what health care setting they work in and among all segments of the population. Nurses must be ready to ask the right questions and to act on the answers, because such action could be lifesaving.
The nurse educator is preparing to teach a group of nurses about intimate partner violence (IPV). Which statement will the nurse include in the teaching session? a). "Alcohol and drug use disorders are the main causes of IPV." b). "IPV is when one partner is physically abused by another partner." c). "IPV is a common form of violence among people in relationships." d). "IPV occurs mainly in heterosexual relationships."
"IPV is a common form of violence among people in relationships." The nurse would state that IPV is a common form of violence that is believed to be the most common, yet the least reported, form of abuse. IPV occurs in all types of relationships, not only in heterosexual relationships. IPV can be physical, mental, sexual, or financial in nature. IPV can be a single type or a combination of the four types. Alcohol and drug use disorders may intensify abusive acts, but these are not the cause of the abuse. An abuser makes the decision to perform abusive acts and often uses alcohol or drugs as an excuse for the act happening.
The nurse working in the obstetrics clinic is completing an assessment and concerned about possible signs of intimate partner violence during pregnancy. Further abuse screening is completed if the nurse documents which? Select all that apply. -Unrealistic fears -Weight fluctuations -Noncompliance with treatment -Difficulty with physical exams -Poor attendance at prenatal visits -More weight gain than recommended
-Poor attendance at prenatal visits -Unrealistic fears -Weight fluctuations -Difficulty with physical exams -Noncompliance with treatment Signs of intimate partner violence can emerge during pregnancy. They may include poor attendance at prenatal visits, unrealistic fears, weight fluctuations, difficulty with physical exams, and noncompliance with treatment. Gaining more weight than recommended is not an indicator of intimate partner violence.
The emergency room nurse is caring for a client who was raped a few hours ago. Which intervention(s) will the nurse perform? Select all that apply. -Send specimens for sexually transmitted infection (STI) testing. -Take the client to an isolated location for assessment. -Refer the client for psychological counseling. -Document the findings in the client's medical record. -Ensure a forensic examination is performed.
-Send specimens for sexually transmitted infection (STI) testing. -Take the client to an isolated location for assessment. -Refer the client for psychological counseling. -Document the findings in the client's medical record.
A community health nurse is speaking at a local Chamber of Commerce luncheon on women's issues related to intimate partner violence. What are some of the myths about violence that the nurse needs to address? Select all that apply. -Women provoke their partners to abuse them. -Violence occurs to only a small percentage of women. -Violence against women occurs only in lower socioeconomic classes. -Women stay in the abusive relationship because they feel they have no options. -Substance use disorder causes the violence.
-Violence against women occurs only in lower socioeconomic classes. -Substance use disorder causes the violence. -Violence occurs to only a small percentage of women. -Women provoke their partners to abuse them. Common myths about violence that the nurse needs to refute include that violence against women occurs in lower socioeconomic classes, that substance use disorder causes the violence, that violence occurs to only a small percentage of women, and that women provoke their partners to abuse them. The statement that women stay in an abusive relationship because they feel like they have no options is factual.
A nurse is reviewing the medical record of a client. Which information would the nurse identify as indicating emotional abuse? Select all that apply. -not allowing the victim to seek care for an injury -controlling how the family's money is spent -forcing the victim to perform a degrading act -threatening to hit the victim -throwing things at a victim -calling the victim names
-calling the victim names -threatening to hit the victim -forcing the victim to perform a degrading act Calling the victim names; promising, swearing, or threatening to hit the victim; and forcing the victim to perform degrading or humiliating acts are examples of emotional abuse. Throwing things at the victim is an example of physical abuse. Controlling the finances and spending is an example of financial abuse. Interfering with a victim's access to health care for injuries is an example of physical abuse.
A nurse is conducting a program for a community group about violence and abuse. As part of the program, the nurse describes the characteristics of the typical abuser. Which characteristics would the nurse include? Select all that apply. -aggression to express inadequacies -withdrawal behavior -feelings of insecurity -antisocial behaviors -violence as a means of control
-feelings of insecurity -aggression to express inadequacies -violence as a means of control -antisocial behaviors Abusers come from all walks of life and often feel insecure, powerless, and helpless, feelings that are not in line with the strong image they would like to project. The abuser expresses feelings of inadequacy through violence or aggression toward others. Violence typically occurs at home and is usually directed toward the intimate partner or the children who live there. Abusers refuse to share power and choose violence to control their victims. They often exhibit childlike aggression or antisocial behaviors. They may fail to accept responsibility or blame others for their own problems. Victims typically react to any expression of anger or threat by avoidance and withdrawal behavior.
Which behaviors are forms of emotional abuse? Select all that apply. -rape -insulting -incest -humiliating -destroying another's property
-insulting -humiliating -destroying another's property Emotional 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.
The nurse who has experience in caring for victims of intimate partner violence knows that goals for a victim may fall into which categories? Select all that apply. -primary prevention -secondary prevention -tertiary prevention -none of the above
-primary prevention -secondary prevention -tertiary prevention Depending on when in the cycle of violence the nurse encounters a victim of intimate partner violence, goals may fall into three groups: primary, secondary and tertiary. Primary is aimed at breaking the cycle of violence, secondary focuses on dealing with the victims and abusers in early stages with goal of preventing progression, and tertiary is geared toward helping victims of severe intimate partner violence recover and become productive members of society.
It is important for a nurse working in pediatrics to understand problems that children face when they have grown up around abuse. Studies indicate that children who witness intimate partner violence are at risk for developing which problems? Select all that apply. -low self-esteem -school failures -developmental problems -failure to thrive syndrome -psychiatric disorders -violence against others
-psychiatric disorders -developmental problems -school failures -violence against others -low self-esteem Children who witness intimate partner violence are at risk for developing psychiatric problems, developmental problems, school failure, violence against others, and low self-esteem. It has not been proven that these children will suffer from failure-to-thrive syndrome.
When caring for victim of intimate partner violence, the nurse uses the ABCDES framework to provide interventions. Which components are part of this framework? Select all that apply -maintenance of confidentiality of the information reported -clear documentation of the nurse's perception of the abuse -reassurance that the victim is not alone in this situation -expression of the belief that there may be a reason for the violence -plan of action and resources for safety for when the victim decides to leave -education about the cycle of violence and its escalation
-reassurance that the victim is not alone in this situation -maintenance of confidentiality of the information reported -education about the cycle of violence and its escalation -plan of action and resources for safety for when the victim decides to leave Use of the ABCDES framework provides direction: reassuring the victim that he or she is not alone; informing the victim of the belief that violence is not acceptable in any situation; ensuring the victim that information reported is confidential; documenting information factually and accurately; educating the victim about the cycle of violence and its escalation; and ensuring the victim's safety by providing the victim with resources and a plan of action to carry out when the client decides to leave. Expressing an opinion that there may be a reason for the violence is never appropriate nor is documenting the nurse's own perception of what happened.
A group of nursing students are preparing a talk on violence against women and how to prevent it. They want to list characteristics of perpetrators of intimate partner violence and should include which characteristics? Select all that apply. -substance and/or alcohol use disorder -negative affect (hostility and depression) -easy-going personality -current unemployment -history of childhood abuse -history of antisocial behavior
-substance and/or alcohol use disorder -negative affect (hostility and depression) -history of childhood abuse -current unemployment -history of antisocial behavior Characteristics of perpetrators of intimate partner violence include substance and/or alcohol use disorder, negative affect, history of childhood abuse, history of antisocial behavior, current unemployment, neighborhood norms that accept violence and substance use, and traditional gender role expectations.
To properly assist a victim of intimate partner violence, which action would be most appropriate for the nurse to do? a). Confront the abuser about the details. b). Summarize the details of the incident. c). Document the details. d). Discuss the details with the victim.
Document the details. Accurate documentation is critical because this evidence may support the client's case in court. Documentation must include details about the frequency and severity of violence; location, extent, and outcome of injuries; and any treatments or interventions. Documentation should always use direct quotes, and be very specific.
A nurse is assigned to care for a client who was brought to the emergency department. The client was a victim of human trafficking. When providing care to this client, which intervention would have priority? a). completing documentation b). building trust c). ensuring safety d). promoting privacy
building trust Although privacy, safety, and documentation are important, the priority for this client would be to build trust.
The generation-to-generation continuum of violence refers to the fact that: a) children who grow up a victim of maltreatment are less likely to be abusers themselves because they see first-hand the devastation that violence can cause. b) children who grow up a victim of maltreatment almost always become abusers themselves unless they have professional intervention. c) violence is an innate behavior, and children become abusers because of external factors in their environment more often than in their family. d) violence is a learned behavior, and children who witness intimate partner violence are more likely to become abusers themselves.
violence is a learned behavior, and children who witness intimate partner violence are more likely to become abusers themselves. Violence is a learned behavior. Many abusers were abused themselves as children; however, not all children who were abused become abusers.
