MODULE 32 VIOLENCE

ABUSE A child is admitted to the hospital with physical injuries. What would indicate to the nurse that the child is a victim of child abuse? Select all that apply. A) Confusion B) Missing teeth C) Inappropriate response to pain D) Abrasions to the mouth, lips, and genitalia E) Dehydration

BCD

A client recovering from a rape tells the nurse that flashbacks do occur but can be managed. Which technique(s) could the client be using to manage flashbacks about the event? Select all that apply. A) Restoring personal choice B) Deep breathing C) Muscle relaxation D) Problem solving E) Guided imagery

BCE

A 19-year-old female student is brought into the Emergency Department by her roommate. The roommate says, "She came home from a party at her boyfriend's house and said that he raped her." Which assessment techniques are appropriate? Select all that apply. A) Inquire how many sexual partners she has had. B) Offer to use a rape evidence collection kit. C) Ask her if she has ever had a sexually transmitted infection. D) Assess for the presence of an intact hymen. E) Ask her if she led her boyfriend on in any way.

BD

The nurse is caring for a victim of rape. What are the priorities of care for this client? Select all that apply. A) Notifying an attorney for the client B) Supporting the victim during the examination C) Identifying the individual who committed the rape D) Treating acute injuries E) Providing referrals for follow-up care

BDE

A 72-year-old male is transported to the Emergency Department after a motor vehicle crash. Which risk factor(s) are most common for this age group? Select all that apply. A) Unsafe driving practices B) Preexisting health condition C) Speeding D) Texting E) Reduced sensory perception

BE

A client is brought into the Emergency Department after being in a motor vehicle accident. The client has suffered traumatic injury that may involve multiple body systems. What is the priority assessment for the nurse? A) Breathing and ventilation B) Circulation with hemorrhage control C) Airway maintenance with cervical spine protection D) Disability and neurological assessment

C

A client presents to the Emergency Department with an incomplete spinal cord injury. The nurse providing care to this client would anticipate which medication would be ordered to decrease inflammation and nerve damage? A) Hydrocodone (Vicodin) B) Ibuprofen (Motrin) C) Methylprednisolone (Medrol) D) Xylocaine (Lidocaine)

C

A client who was raped refuses to see any male physicians, tells the nurse that she had an "incident" that she does not want to talk about, and wants a bed by the door. The nurse identifies which diagnosis as being appropriate for the client at this time? A) Relocation Stress Syndrome B) Readiness for Enhanced Power C) Rape-Trauma Syndrome D) Acute Confusion

C

A client who was raped tells the nurse that she must not get pregnant. What would be an appropriate response by the nurse? A) "The baby could always be given up for adoption." B) "You will not know for sure for at least a few more days." C) "There is a medication called Plan B, which is emergency contraception." D) "Are you sure the rapist did not use a condom?"

C

A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. The nurse realizes this client has identified a: A) Predisposing factor. B) Risk factor. C) Vulnerability factor. D) Precipitating factor.

C

A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle crash. Which would be the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications? A) Provide active or passive exercises at least once every 8 hours. B) Encourage coughing, deep breathing, and incentive spirometry. C) Assist the client in turning at least every 2 hours. D) Assist the client in turning at least every 8 hours.

C

A pediatric nurse is caring for an 18-month-old infant. While making rounds the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take? A) Discuss what she witnessed with the infant's mother. B) Discuss what she witnessed with the other nurses. C) Report what she witnessed and assessed to child protective services. D) Report what she witnessed and assessed to the local law enforcement agency.

C

A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted trichomoniasis. The clinic nurse would anticipate which pharmacological treatment will be prescribed? A) Penicillin B) Ceftriaxone and azithromycin C) Metronidazole D) Doxycycline

C

A school-age client is admitted with dog bites and scratches obtained when throwing rocks at a neighbor's dog. What should the nurse do to help this client? A) Tell the client that he might go to jail for hurting the dog. B) Ask the client where his parents were when he was hurting the dog. C) Suggest to the client that it is not okay to harm animals. D) Ask the client what he intended to accomplish by hurting the dog.

C

A young female client comes into the Emergency Department with vague physical symptoms and does not make eye contact with the nurse during the interview. Which question should the nurse ask to gain understanding of the client's situation? A) "What kind of problems are you having?" B) "Can you tell me what's been going on in your life lately?" C) "Is someone hurting you?" D) "Can you explain what your family life is like?"

C

ASSAULT AND HOMICIDE An adolescent client with fetal alcohol syndrome was arrested for assaulting another teenager after being distracted and missing the school bus. The nurse realizes the client's outburst was most likely due to: A) Dislike of the other teenager. B) Fetal alcohol syndrome. C) Fetal alcohol syndrome and an environmental stressor. D) Anger over being distracted.

C

An adolescent client hospitalized with asphyxiation from a failed suicide attempt tells the nurse, "I know other kids have the same problems I do, but I just wanted to make it stop." What should the nurse do to help this client? A) Discuss the client's attendance at school and what activities are enjoyed. B) Suggest the client listen to music and read a light novel to reduce stress. C) Ask if the client would like to talk about stressors and problems. D) Ask what is so devastating that the client needed to commit suicide.

C

The Emergency Department nurse is caring for a client with multiple injuries. The client has had a diagnostic peritoneal lavage to determine the presence of blood in the peritoneal cavity. Which result would indicate to the nurse that the diagnostic test is considered positive? A) The solution returns pale pink and is found to have a white blood cell count of < 500. B) The solution returns pale pink and is found to have a red blood cell count of 50,000 mm3. C) The solution returns pink and is found to have bile, food, or feces. D) The solution returns clear and is found to have a red blood cell count of 90,000 mm3.

C

The family of a victim of a gunshot wound is asking Emergency Department personnel if they could find out the status of their family member. What should the nurse do to assist the client's family? A) Suggest they go to the cafeteria to get something to eat or drink. B) Suggest they return home, and the hospital will phone them with any information. C) Contact social services or the hospital chaplain to provide support while they wait. D) Escort the family to see the client.

C

The nurse is completing a morning assessment on a 68-year old Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. What would be an appropriate action for the nurse? A) Contact adult protective services. B) Call the physician immediately. C) Assess the client's spiritual beliefs. D) Contact the client's family.

C

The nurse is working in orthopedics and is discharging Mrs. Snell, who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with her husband. When she says, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw we went to Rome." What does the nurse assess Mrs. Snell is anticipating? A) A tension phase B) An abusive phase C) A honeymoon phase D) A stop to the violence E) Reconciliation and healing

C

What would be appropriate interventions for a victim of interpersonal violence? Select all that apply. A) Educating the client on how to avoid future incidents of violence B) Distracting the client to avoid overwhelming feelings about the situation C) Using a supportive, nurturing approach D) Helping the client identify intra- and interpersonal strengths E) Maintaining objectivity and offering short, to-the-point responses

CD

When caring for an abused child, what should the nurse do? Select all that apply. A) Ask the child what he did to cause his parents to beat him so badly. B) Tell the child that the individual who hurt them is a bad person. C) Follow protocols for mandatory reporting. D) Remind the child that he did nothing wrong. E) Ask the child what really happened.

CD

A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply. A) Explore options for self-development. B) Improve quality of life by increasing self-esteem. C) Explore options for help. D) Convey safety. E) Determine immediacy of danger.

CDE

What does the nurse recognize as risk factors for the abuse of a 2-year-old client? Select all that apply. A) The child has bruises on the knees and shins. B) The child's parents are married. C) The child is less than 3 years old. D) The child is deaf. E) The child's parents are unemployed and receive medical assistance.

CDE

) A client admitted for injuries sustained in a motor vehicle crash tells the nurse that he was hurt much worse the last time he crashed. Which should the nurse do to assist this client? A) Report the client to the department of motor vehicles. B) Find out what caused today's car accident. C) Ask if he enjoys crashing his cars. D) Suggest attending a driver's safety course to learn how to avoid crashes.

D

A client is brought into the Emergency Department after being assaulted. It is suspected that the client has a spinal cord injury. Which diagnostic test would be performed if this type of injury were suspected? A) Computed tomography (CT) scan B) X-ray C) Ultrasound D) Magnetic resonance imaging (MRI)

D

A nursing instructor is evaluating a nursing student's knowledge regarding a client with suicidal thoughts. Which statement made by the student demonstrates an understanding regarding assessing a client with suicidal thoughts? A) "I should attempt to make light of the circumstances." B) "I should be indirect and respectful." C) "I should not talk about suicide directly." D) "I should directly acknowledge the situation."

D

An older client is admitted with fractured femurs sustained in a motor vehicle crash. Once the client is stabilized, what should the nurse assess in this client? A) Blood pressure B) Need for assistance once discharged to home C) Car insurance carrier D) The client's accident history

D

SUICIDE ) A client often asks what life would be like if he had never been born or if he were to die. What does the nurse suspect this client is at risk for? A) A suicide attempt B) Suicide planning C) A suicide threat D) Suicidal ideation

D

THE CONCEPT OF VIOLENCE A young client is brought into the Emergency Department by a friend who says the client was "beat up" at school. The client is reluctant to provide the names of parents or a home address. What should the nurse suspect has occurred with this client? A) The client does not want the individual who did the beating to get in trouble. B) The client does not know his parents. C) The client does not want the school to get in trouble. D) The client is a victim of interpersonal violence.

D

The nurse caring for a client recovering from a suicide attempt determines that care has been beneficial to eliminate future suicide attempts when the client states: A) "I am not looking forward to going home with my parents." B) "I now know that threatening suicide will help me get what I want from my parents." C) "Even though I failed this time, I lived to think about it again." D) "I am looking forward to going to school and seeing my friends." Answer: D

D

The nurse is caring for a client that is the victim of domestic violence and is visited by the spouse in the hospital. What should the nurse do to support the client? A) Call the police to have the spouse arrested for assault. B) Refuse to permit the spouse to visit with the client. C) Call security to have the spouse removed. D) Ask the client if there is anything that is needed at this time.

D

The nurse is working with a client to create a crisis care card in the event the client wants to attempt suicide in the future. What should be included on this card? A) Name of client's physician B) Name of client C) Address of client D) Name and address of friends to call in case of a crisis

D

UNINTENTIONAL INJURY MVC A client recovering from a motor vehicle crash develops hypotension and severe jugular distension with a tracheal deviation. What does the nurse suspect has occurred? A) Hemorrhage B) Compensatory shock C) Hypovolemic shock D) Tension pneumothorax

D

What should the nurse do to assist a client brought to the Emergency Department as a victim of a gunshot wound? A) Ask the client who shot him. B) Bathe the client and provide a clean gown. C) Ask the client where the weapon is. D) Preserve the chain of evidence.

D

A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate? A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem

A

A nurse is interviewing a client with a recent suicide attempt. What would be an appropriate question for the nurse to ask? A) "Do you currently have a plan for killing yourself?" B) "Why would you think about hurting yourself?" C) "Have you thought about hurting yourself?" D) "Do you ever think about hurting yourself?"

A

A nursing instructor is educating a group of students on culture and diversity as it relates to homicide. Which statement made by a student nurse would indicate to the instructor that further education is needed? A) "Caucasian individuals are more likely to use a gun as a means of homicide than any other weapon." B) "Stranger homicides typically are not interracial." C) "The homicide rate among African American individuals is considerably higher than that among individuals of other races." D) "Caucasian individuals are significantly more likely to commit homicides involving multiple victims."

A

A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted syphilis. The clinic nurse would anticipate which pharmacological treatment will be prescribed? A) Penicillin B) Ceftriaxone and azithromycin C) Tinidazole D) Doxycycline

A

After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. What should occur next? A) Conduct a team assessment. B) Medicate for anxiety as prescribed. C) Notify the police. D) Treat the injuries.

A

Security was contacted to remove a handgun from the pants pocket of a client who had been admitted with wounds sustained in a fight. Which diagnosis should the nurse include in this client's care plan? A) Risk for Violence to Others B) Risk for Loneliness C) Risk for Situational Low Self-Esteem D) Fear

A

What can the nurse do to assist a client who was raped identify and prioritize concerns? A) Help the client use problem-solving skills. B) Provide anti-anxiety medication. C) Tell the client that the event is over and it is now time to move on. D) Instruct in guided imagery.

A

What would the nurse's care plan include for a client who has experienced spousal abuse resulting in several fractures? A) Assist the client to devise a safety or escape plan. B) Encourage the client to take charge of the situation. C) Offer to contact outpatient services if the client promises not to return home after discharge. D) Make it clear to the spouse that the couple needs to see a therapist.

A

A nurse is conducting an admission assessment on a client admitted for thoughts of suicide. The nurse is determining the client's risk for suicide. Which would indicate to the nurse that the client is at a low level risk of suicide? Select all that apply. A) Displays mild depression. B) Shows curiosity about death. C) Discusses taking his or her life. D) Admits planning to end his or her life. E) Discusses a plan to end his or her life in detail.

AB

The nurse is planning care for a client to prevent future suicidal behavior. Which interaction(s) would be appropriate for this client? Select all that apply. A) Add the names of community resources to a crisis card. B) Assist in creating a crisis card listing family members. C) Focus on reasons for living. D) Limit exposure to friends. E) Identify self-directed harmful behaviors.

AB

An elderly client is brought into the Emergency Department for a recent fall. The nurse suspects elder abuse. What are clinical manifestations of elder abuse? Select all that apply. A) Poor hygiene B) Dehydration C) Intracranial trauma D) Fecal impaction E) Dislocations

ABDE

The nurse determines that a client is at risk for being raped when which characteristic or characteristics are assessed? Select all that apply. A) Previous history of being raped B) Current substance abuse C) Lives with parents D) Attends community college E) Unemployed

ABE

The nurse is planning care for a client recovering from injuries sustained in a gang fight. What should be included in this client's plan of care? Select all that apply. A) Need for adequate rest and physical activity B) Methods to reduce anger other than force or physical violence C) Employment counseling D) Monitor intake and output E) Setting limits

ABE

The nurse working in the Emergency Department is aware that rape victims initially exhibit which emotions? Select all that apply. A) Shock B) Disbelief C) Anger D) Self-blame E) Denial

ABE

The school nurse is leading a discussion on violence with a group of teens. Which factors could the school nurse indicate to the teens as protective factors that may decrease the risk of violence? Select all that apply. A) Involvement in the community B) Participation in family activities C) Residing in an impoverished community D) Academic failures at a young age E) Success in school

ABE

What would the Emergency Department Nurse identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply. A) Airway maintenance B) Obtaining medical history C) Ventilation assistance D) Hemorrhage control E) Hypothermia prevention

ACDE

RAPE AND RAPE TRAUMA SYNDROME The nurse is caring for a client who was raped. What does the nurse understand as the underlying issue of most rapists? Select all that apply. A) A desire to overpower and control B) A desire to play out fantasies C) An uncontrollably strong sex drive D) The inability to control intense anxiety E) Acting out aggression

AE

Which of the following are appropriate ongoing, long-term treatment goals for a victim who experienced sexual abuse 8 months ago? Select all that apply. A) Demonstrate effective coping strategies. B) Involve significant others in the treatment plan. C) Become aware of legal rights. D) Establish rapport and build a trusting nurse-client relationship. E) Move from victim to survivor status.

AE

A client recovering from injuries obtained from a domestic dispute asks to attend Mass at the hospital chapel. The nurse understands that it is important for the client to: A) Find a distraction from the injuries. B) Attend to spiritual needs in order to deal with what has happened. C) Show an interest in what is going on in the world. D) Get back to a normal routine as soon as possible.

B

A client was admitted with a gunshot wound sustained during a robbery. What does the nurse suspect contributed to this client's injury? A) The crime's suburban location B) The gunman's unemployment C) The gunman's age of 45 D) The gunman's college education

B

A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective? A) "Everyone knows what my problems are, and there is nothing I can do about it." B) "I am functioning fine now but I know that when problems come up again, I will ask for help." C) "My friends tell me that I have improved so this is a good time to stop." D) "It is so draining to deal with the same painful issues all of the time."

B

A client with a history of frequent outbursts and fighting has been receiving treatment to help control emotions and anger. Which client statement shows that treatment has been effective? A) "My brothers are the only ones I can fight with and not get in trouble." B) "There are other ways to deal with anger, and I will use them instead of fighting." C) "Hitting people is only justified sometimes." D) "As long as my mother doesn't hit me first, I will not hit her."

B

The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. What should the nurse include as a goal of care for this client? A) Have an adequate urine output. B) Regain mobility. C) Participate in self-care activities. D) Discharge to home.

B

The parents of a client who committed suicide are observed arguing in the Emergency Department waiting area. What does the nurse realize the parents are at risk for developing? A) Risk for violence B) Ineffective family coping C) Anxiety D) Situational low self-esteem

B

Which observation indicates that interventions provided to a client with neck injuries from a motor vehicle crash have been successful? A) Urine is clear and odorless from indwelling catheter. B) Moves all four extremities independently, feeds self, and participates in partial bath C) Unable to move independently in bed D) Rests in bed with lights and television turned off

B