Mental Health: Violence

Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?

Risk for other-directed violence R: The priority nursing diagnosis is risk for other-directed violence.

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. R: The client is at risk of committing suicide. The therapy should first be focused on keeping the client physically safe.

The nurse suspects sexual maltreatment in a 10-year-old girl. The nurse would assess which primary finding to help make this determination?

vaginal discharge R: An inspection of the external genitalia should be done at each yearly health assessment. An assessment for vaginal discharge or irritation should be done if the girl reports these problems or if sexual maltreatment is suspected. A vaginal discharge that suggests infection or a fourchette tear in a young girl may be an indication of sexual maltreatment. In the adolescent, these signs can be an indication of rape

A client is receiving treatment for injuries sustained during a fight with a partner. The nurse observes the partner visit the client daily in the hospital and appears very solicitous and contrite. The client states, "My partner always apologizes and brings gifts after a fight." Which response by the nurse is appropriate?

"Although your partner seems sorry, often an abuser will continue to repeat the behavior in the future." R: The nurse should clearly explain to the client that whatever the cause of the incident, no one deserves to be a victim of intimate partner violence and abusive behaviors are often repeated.

A psychiatric-mental health nurse is conducting an in-service education program about suicide for a group of nurses working at a community mental health center. The nurse determines that the teaching was successful based on which statement by the group?

"Suicide has profound effects on those connected to the individual." R: Suicide is a major public health concern, both in the United States and around the world. Although certain factors may increase risk for suicide, suicide knows no bounds of person, age, class, race, or gender. It is an act that profoundly affects those left in its wake. Suicide among the older adult population has increased.

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 R: It is highly plausible that the client has post-traumatic stress disorder, given the high incidence and prevalence among veterans. Assessment should precede any interventions such as family meetings or education sessions.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?

Collaborate with the physician to make a referral to social services. R: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report.

A client with multiple bruises comes to the clinic for treatment. The client appears withdrawn and quiet when communicating with the nurse. The spouse accompanies the client to the exam room and begins to answer all the questions the nurse asks the client. Which action will the nurse take next?

Escort the client to a private area to complete the assessment. R: One major indicator of intimate partner violence is the hovering behavior of the abusive partner during a visit. The client also has multiple bruises and is very quiet. The nurse needs to speak with the client privately to ask about IPV. After completing the assessment, the nurse would notify the primary health care provider and document the findings. The nurse may also need to report the findings to the proper authorities

A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse?

Report suspicion of elder abuse to the local agency for older adults. R: Physical injuries and withdrawing from normal activities are signs of potential elder abuse. The nurse must report the suspicion of elder abuse to the local agency that deals with the well-being of older adults (e.g., adult protective services).

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect?

Stalking R: Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency (CDC, 2016b). Stalking is a crime of intimidation. Stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Stalking may include such behaviors as following someone, showing up at the person's home or workplace, vandalizing property, or sending unwanted gifts.

The nurse is caring for a client with aggression disorder. The client has an anger episode and is threatening other clients in the emergency room with a knife. What should be the approach of the nurse in this situation? Select all that apply.

The nurse should attempt to kick the knife out of the client's hand. The nurse should call for outside assistance. R: When necessary to remove the weapon, the nurse should try to kick the weapon out of the client's hand. The nurse should not reach for a weapon with his or her hand. The nurse should know the hospital's staff assistance plan and summon for outside assistance, especially in the event the client has a gun. The nurse should talk to the client in a low, calm voice; yelling may only exacerbate the situation.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing

raccoon's eyes and Battle's sign. R: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing?

resistance stage R: The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore.

The nurse is interviewing a 13-year-old girl with depression. During the course of the interview, the girl reveals that her best friend is thinking about committing suicide. Which response by the nurse would be most appropriate?

"Do you know how she is planning to kill herself?" R: Because the girl is depressed, the nurse suspects that the girl is indirectly talking about herself, not her best friend. When an adolescent raises the issue of suicide, it is important to find out exactly how he or she is envisioning suicide and take measures to prevent an attempted suicide. Therefore, the nurse should ask how the "friend" is contemplating suicide in order gather this information and open a dialogue to encourage the girl to reveal she is talking about herself.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

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

While caring for a client in the hospital, the nurse becomes concerned that the client may be having thoughts of suicide. Which statement would be most therapeutic?

"I've noticed something is bothering you. Please share you thoughts with me." R: Nurses start with expressing what the nurse is noticing. This type of communication communicates objectivity and helps minimize defensiveness or minimization.

The nurse suspects a pregnant client is a victim of intimate partner violence (IPV). When the nurse asks the client if her partner abuses her, the client responds, "Oh no, my partner does not hit me." Which response by the nurse is most appropriate?

"There are many types of intimate partner violence beyond physical abuse." R: The nurse would explain the different types of IPV to the client, such as emotional, sexual, and financial abuse. The client may not understand her current situation is considered IPV even though it is not physical abuse.

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 (child mistreatment) in which situation?

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. R: Spiral fractures, which twist around the bone, are frequently associated with child abuse (child mistreatment) and are caused by a wrenching force.

A 20-year-old client was admitted to the inpatient unit following a suicide attempt. The client is disheveled, disorganized, and dehydrated. The priority for the client's care during the first 24 hours of admission will be what?

Assessing the client's current suicidal ideation and putting the client on suicide precautions. R: The first step is to provide for the client's safety by assessing the risk for suicide. Because the client has attempted suicide, the nurse immediately places the client on suicide precautions with frequent or continuous one-to-one observation and reassessment.

A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?

Client will express that the client feels safe on the unit R: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope.

Which statement regarding gender and suicide is correct?

Females engage in suicidal behaviors more frequently than males. R: While females engage in suicidal behaviors approximately three times more frequently than males, males are at least four times more likely to die from suicide. This outcome may be because men generally tend to choose more violent methods. In the United States, two thirds of male suicide victims die by firearm. The most common cause of death by suicide in women is overdose or poisoning.

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 R: Neglect is the most common type of elder abuse. Other types include physical, emotional, sexual, and financial abuse.

During an assessment, which would be the most important question topic?

Suicidal ideation R: The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

Levels A, B, and C are levels assigned to potential agents of bioterrorism. What are these categorical assignments based on?

Transmissibility R: Potential agents of bioterrorism have been categorized into three levels (A, B, and C) based on risk of use, transmissibility, invasiveness, and mortality rate.

A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response?

Warn the client's neighbor and report to the authorities. R: When the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn.

A school nurse is developing a plan of care for a child with suspected violence between the child's parents. The nurse monitors for which behaviors in the child?

aggressive behavior in school R: Children who have a parent who is violent may be identified because of behavior problems, noncompliance, and aggression in school.

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance R: The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member.

The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ...

have their needs met. R: The nurse should explain to the new staff member that some clients use violence and aggression to get what they want or to force change or regain control. The client may also be seeking attention.

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

postpartum depression R: Several studies have confirmed the relationship between intimate partner violence and poor mental health, especially depression. For the pregnant woman, this most often manifests itself as postpartum depression.

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?

stocking-glove pattern on hands or feet R: A stocking-glove pattern on the hands or feet or a circumferential ring appearing around the extremity points to the caregiver forcefully holding the child under extremely hot water.