IPV

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best? "What do you mean by that statement?" "Are you thinking of hurting yourself?" "Have you been taking your medications?" "Have you felt like this before?"

"Are you thinking of hurting yourself?" *Risk of suicide is greater in patients with a serious illness, including mental or emotional disorders. The nurse should recognize the client's statement as a warning for possible self-harm. With this concern, the nurse should ask the client a yes/no question regarding self-harm. Using an open-ended question is therapeutic, but assessing the risk of self-harm requires a more direct approach. Asking about medications or past feelings should wait until after the risk for self-harm is determined.

An adolescent client has recently ended a physically and emotionaly abusive initimate relationship. What nursing assessment question(s) will help identify a commonly associated comorbid mental health problem? Select all that apply. "How much alcohol do you drink in an average week?" "Do you ever have thoughts of hurting or killing yourself?" "Are your teachers satisfied with the grades you earn in school?" "How would you alter your eating habits in order to lose weight?" "Has anyone every told you that you had a problem with your temper?"

"How much alcohol do you drink in an average week?" "Do you ever have thoughts of hurting or killing yourself?" "Are your teachers satisfied with the grades you earn in school?" "How would you alter your eating habits in order to lose weight?" *Adolescents who experience violence in intimate relationships are more likely to develop problems such as depression with consideration of suicide, substance use disorders including alcohol use disorder, eating disorders resulting in weight loss, and poor school performance. While not impossible, anger management issues are not as commonly associated with this client's situation.

The nurse is caring for a client with a history of aggression toward staff. The client, who is currently being verbally threatening, stands up and says to the nurse, "What are you going to do about it?" What response by the nurse will best de-escalate the situation? "If you don't calm down, I'll have to have someone restrain you." "I'm concerned about you. Can you tell me what you're going through right now?" "The only thing I want to do is help you. Tell me what I can do." "I can see you're upset right now. I'll come back when you're ready to talk calmly."

"I'm concerned about you. Can you tell me what you're going through right now?"

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this? "My partner always tells me that the abuse never happened." "My partner tells me who I can and cannot see." "My partner tells me that he or she will tell child services I'm a bad parent." "My partner acts like the master of the castle and I'm the servant."

"My partner tells me that he or she will tell child services I'm a bad parent.

While interviewing an adolescent client with depression, the client reveals to the nurse that he has considered hurting himself. Which response by the nurse would be most appropriate? "Tell me exactly how you would hurt yourself." "Why would you want to hurt yourself." "Do your parents know that you want to hurt yourself?" "Have you discussed this with anyone else?"

"Tell me exactly how you would hurt yourself.

Research has shown that risk of suicide increases within which time frame for initiation of antidepressant therapy? 14 days 28 days 35 days 42 days

14 days

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which situation? A 10-year-old with a simple fracture of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs. A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. A 9-year-old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard. A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports as having been caused when the child fell while ice-skating.

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate.

Which characteristics are found in violent families? Select all that apply. Adequate support systems Abuse of power and control Alcohol use disorder Social isolation

Abuse of power and control Alcohol use disorder Social isolation

Which is the most likely weaponized biological agent available? Plague Anthrax Botulism Smallpox

Anthrax

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action? Assess the client for signs and symptoms associated with post-traumatic stress disorder Educate the family about the usual emotional responses to returning home from military service Organize a family meeting where family members can tell the client how they feel Educate the family about the relationship between hyperarousal and emotional distance

Assess the client for signs and symptoms associated with post-traumatic stress disorder

A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing? Triggering Escalation Crisis Recovery

Crisis

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply. Criticizing Ridiculing Threatening a victim's dog Asking for time alone when frustrated Using assertive language

Criticizing Ridiculing Threatening a victim's dog

A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client's suicidal risk has lessened considerably, and the client currently denies having any desire to kill himself or herself. In addition, the client is able to identify reasons why the client wants to be alive. Which nursing intervention would be most appropriate at this time? Assigning nursing staff to stay with the client during the suicidal crisis Developing a personal plan for managing suicidal thoughts when they occur Advising the client to consider electroconvulsive therapy treatments Administering psychotropic drugs that decrease the client's serotonin levels

Developing a personal plan for managing suicidal thoughts when they occur

A nurse is conducting a discussion group at a local women's health center about violence and women. The nurse would include that women are at a higher risk for violence at which time? during pregnancy during winter on paydays if they leave the abuser

During Pregnancy

A client is admitted to a mental health unit because the client was found trying to inject diluted feces into the client's hospitalized child's intravenous line. The client has a history of similar attempts of harming the child. The nurse would most likely suspect what? Schizoid personality traits Factitious disorder imposed on another Functional neurologic symptoms Borderline personality disorder

Factitious disorder imposed on another

A 15-year-old client with intermittent explosive disorder (IED) gives no history of childhood abuse, neglect, or maltreatment. What could be the cause of the disorder in this client? Imbalance in the production of serotonin Dysfunction of the parietal lobe Depleted levels of glucose in the blood Presence of coronary artery disease

Imbalance in the production of serotonin

The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include? Lesbians and bisexual females are more likely to be underweight or anorexic. LGBT populations have lower rates of tobacco, alcohol, and other drug use. LGBT youth are 2 to 3 times more likely to attempt suicide. Lesbians are more likely to get preventive services for cancer.

LGBT youth are 2 to 3 times more likely to attempt suicide.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Stomach Large intestine Kidneys

Liver

Students are preparing a class presentation on elder abuse. Which of the following would they include as the most common type of elder abuse? Neglect Emotional Financial Sexual

Neglect

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Protecting himself or herself Securing the area Gaining control of the situation Providing care to the injured

Protecting himself or herself

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are mostappropriate? Select all that apply. Provide explanations and support to the client. Attend to the client's physical needs. Ask the client to leave. Tell the client their secret is safe. Report any signs of abuse to appropriate agencies.

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first? Devising an escape route Recognizing the signs of danger Identifying a safe place to hide Identifying a signal to indicate it is safe to leave

Recognizing the signs of danger

The nurse is caring for a client with major depressive disorder who has been admitted to a psychiatric-mental health facility. After assessing the client, the nurse has developed a nursing diagnosis of "risk for violence toward others related to agitation and low tolerance level." Which would be an appropriate intervention for this client? Encourage the client to engage in calming group activities. Remove all dangerous items from the client's room. Provide antianxiety medication to prevent an incident. Encourage the client to act on thoughts that are leading to aggression.

Remove all dangerous items from the client's room.

Many people have experienced some kind of traumatic event in their lives. While response to trauma varies with individuals, what is a generalized response in those who have experienced severe trauma in childhood? Little response, since children quickly forget Immediate, strong response which declines as time passes Response later in adulthood that manifests itself in medical and mental issues No response once the trauma is over

Response later in adulthood that manifests itself in medical and mental issues

After observing a bipolar client on the mental health unit, the nurse determines that the client is at risk for violence. Which would be an appropriate intervention? Ask the client to sit alone and write a letter. Restrict the client to the client's room until the client can calm down. Encourage the client to participate in an activity with other clients. Tell the client that if the client is violent, the client will be sent home.

Restrict the client to the client's room until the client can calm down.

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority? Hopelessness related to recent divorce Ineffective coping related to inadequate stress management Spiritual distress related to conflicting thoughts about suicide and sin Risk for suicide related to highly lethal plan

Risk for suicide related to highly lethal plan

Which type of rapist derives erotic gratification from the victim's suffering? Sadistic rapist Power rapist Anger rapist Premeditated rapist

Sadistic rapist

A pregnant client presents to the emergency department with complaints of back pain. This is the second visit in a month. She is accompanied by her spouse, who refuses to let the client speak for herself. When inspecting the painful area, the nurse notes bruising on the client's lower back. The client's spouse states that the client is clumsy and falls down the front steps of the house often. What should the nurse do first in this situation? Assess the fetal heart rate. Provide a list of community resources. Separate the pregnant client from her partner. Assess the client's safety.

Separate the pregnant client from her partner

A nurse is with an adolescent who reports nothing to live for and wishing to be dead. Which nursing action would be the priority? Going to the client's psychiatrist to report the suicidal ideation Staying with the client to explore more of the client's thoughts about suicide Putting the client in seclusion with a staff member assigned to watch the client at all times Ascertaining the client's beliefs about what happens when you die

Staying with the client to explore more of the client's thoughts about suicide

Trying to kill oneself and surviving the ordeal is identified as what? Suicide attempt Parasuicide Suicidal behavior Suicidal ideation

Suicide attempt

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status

Which court decision or act states that psychotherapists have a duty to exercise reasonable care in protecting the foreseeable victims of their clients' violent actions? Tarasoff v. Regents of the University of California The Patient Self-Determination Act The Mental Health Systems Act of 1980 Public Law 99-319, The Protection and Advocacy for Mentally Ill Individuals Act of 1986

Tarasoff v. Regents of the University of California

The nurse is caring for a client with severe depression. The client tells the nurse, "I really just want to sleep and not have to wake up." What may the nurse interpret from this covert cue? The client may want to sleep. The client may be extremely fatigued. The client may have suicidal ideations. The client may need a break to reduce stress.

The client may have suicidal ideations.

Following an assessment of a client with posttraumatic stress disorder (PTSD), the nurse concludes that the client is at risk for suicide. What would be the immediate goals of management for this client? The client will be physically safe. The client will express emotions nondestructively. The client will establish a social support system in the community. The client will demonstrate effective ways of dealing with stress.

The client will be physically safe.

A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline? The nurse should avoid touching the client during interactions unless necessary The nurse should ensure that a colleague is present when the client is assessed The nurse should encourage the client to use progressive relaxation techniques rather than prescribed medications The nurse should encourage limiting contact with friends and family until the client's mood improves

The nurse should avoid touching the client during interactions unless necessary

The emergency department nurse is obtaining a history from the parents of a 4-year-old child. Multiple bruises and abrasions are noted. The nurse highly suspects child abuse based on which finding? The stories about the accident or injury from the parents conflict. The history is consistent with the child's injuries. The parents appear unkempt and have low socioeconomic status. The parents have a flat affect and appear emotionally detached from the child.

The stories about the accident or injury from the parents conflict

The nurse provides care to individuals who have been sexually assaulted during their childhood. Which characteristic is most commonly noted by the nurse during an assessment of such clients? Overly self-confident Unusually aggressive Overly social Too trustful

Unusually aggressive

When conducting a suicide risk assessment, the nurse understands that which method has the least lethality? Hanging Wrist slashing Overdose of benzodiazepines Jumping

Wrist slashing

A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate: tearfulness. aggression. withdrawal. apathy.

aggression

A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: check the client frequently at irregular intervals. assure the client that the nurse will hold in confidence anything the client says. repeatedly discuss the client's previous suicide attempts. disregard decreased communication by the client because decreased communication is typical of suicidal clients.

check the client frequently at irregular intervals.

The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases? honeymoon phase tension-building phase battering incident hopeless stage

honeymoon phase

The nurse is assessing an adolescent in a psychiatric facility. The parent tells the nurse that the adolescent has intense sporadic anger episodes. The adolescent becomes angry for petty reasons and starts throwing objects at home. The adolescent also feels guilty and repents for the actions. Based on this history, the nurse would expect the client to be diagnosed with: dementia. depression. paranoid delusions. intermittent explosive disorder.

intermittent explosive disorder

An adolescent at 8 weeks' gestation is at her first prenatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question? mood mental status intimate partner violence social history

intimate partner violence

When a pregnant client is victim of intimate partner violence during pregnancy, what complication is likely to occur after birth due to the abuse? edema postpartum depression low birth weight schizophrenia

postpartum depression

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement? reaction formation rationalization repression regression

repression

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? collecting semen performing the pelvic examination obtaining consent for examination supporting the client's emotional status

supporting the client's emotional status

The nursing instructor is teaching about violence and informs the students about which of its distinct phases? Select all that apply. tension-building phase prehoneymoon phase acute battering phase honeymoon phase courting phase

tension-building phase acute battering phase honeymoon phase