NCLEX Questions (3rd Edition)

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the persons underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

A Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Anger b. Concern c. Empathy d. Compassion

A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, I will never be the same again. I can't face my friends. There is no sense of trying to go on. Select the nurses most important response. a. Are you thinking of suicide? b. It will take time, but you will feel the same as before. c. Your friends will understand when you tell them. d. You will be able to find meaning in this experience as time goes on.

A The victims words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victims needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

Which behavior best demonstrates aggression? a. Stomping away from the nurses station, going to another room, and grabbing a snack from another patient. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, I felt angry when you said I could not have a second helping at lunch. d. Telling the medication nurse, I am not going to take that or any other medication you try to give me.

A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.

A patient tells the nurse, My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication when the patient feels angry.

A Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, Back off! and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arms length distance from the patient. d. sit down in a chair near the patient.

A Making sure space is present between the nurse and the patient avoids invading the patients personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurses exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patients aggression is abating. One arms length is inadequate space.

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

A Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

An 11-year-old child says, My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn. Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

A The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

A The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3- year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the fathers unmarried sister who has come to visit for 2 weeks

A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adults daughter, who becomes defensive and says, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

A The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. It's so frustrating. Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. Tell me how you punish your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. d. Do you or your husband ever beat the children? e. Calling children stupid injures their self-esteem.

A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesn't like me. He calls me stupid all the time. The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patients privacy may be compromised by the presence of family. The rape victims anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that staff take which actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

A, B, D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Because an intervention is required to control a patients aggressive behavior, a critical incident debriefing takes place. Which topics should be the focus of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

A, C, D The patients behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.

When an emergency department nurse teaches a victim of the rape about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

A, C, D These reactions are common to the long-term reorganization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, You are behaving inappropriately. d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

A nurse works with a person who was raped four years ago. This person says, It took a long time for me to recover from that horrible experience. Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

B A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. She was very beautiful. b. I gave her what she wanted. c. I have issues with my mother. d. I've been depressed for a long time.

B Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Administer lorazepam (Ativan) every 4 hours to reduce the patients anxiety.

B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice.

A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for not knowing enough to give me pain medicine when I need it. Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of intimate partner violence. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, Would you like to come to your room and take some medication your doctor prescribed for you? b. accompanied by three staff members and say, Please come to your room so I can give you some medication that will help you feel more comfortable. c. and place the patient in a basket-hold and then say, I am going to take you to your room to give you an injection of medication to calm you. d. accompanied by two security guards and tell the patient, You can come to your room willingly so I can give you this medication, or the aide and I will take you there.

B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability.

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, You may not leave until you receive prophylactic treatment for sexually transmitted diseases. b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

What is a nurses legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patients right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

B In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

B Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

A rape victim tells the emergency department nurse, I feel so dirty. Please let me take a shower before the doctor examines me. The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A persons lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

B Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patients condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patients treatment is completed.

B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouses presence and concerns. The incorrect options are likely to increase anger because they imply that the anxiety is inappropriate.

After treatment for a detached retina, a victim of intimate partner violence says, My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me. Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partners physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship.

B Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patients use of defense mechanisms.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to under involvement with the victim. d. Positive feelings promote the development of sympathy for patients.

B Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, I want to go to school, but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn. What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

B The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurses immediate attention? a. I hate all of you! b. My fingers are tingly. c. You wait until I tell my lawyer. d. It was not my fault. The other patient started it.

B The correct response indicates impaired circulation and necessitates the nurses immediate.

A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, You stay together, no matter what happens. Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

B The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.

An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patients adult child. This caregiver becomes defensive and says, It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep. Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mothers evening and night care. c. Support the caregiver to grieve the loss of the mothers ability to function. d. Teach the family how to give physical care more effectively and efficiently.

B The patients child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

A patient being admitted suddenly pulls a knife from a coat pocket and threatens, I will kill anyone who tries to get near me. An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

B The patients threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion.

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, I can't believe I've been raped. This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

B The victims response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.

A patient with burn injuries has had good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patients usual schedule is. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse managers best response? a. Explain the reasons for the disorganization, and take over the patients care for the rest of the shift. b. Acknowledge and validate the patients distress and ask, What would you like to have happen? c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patients feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. Reported should be used instead of alleged. Penetration should be used instead of intercourse. Declined should be used instead of refused.

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victims comments.

C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement

A rape victim tells the nurse, I should not have been out on the street alone. Which is the nurses most therapeutic response? a. Rape can happen anywhere. b. Blaming yourself only increases your anxiety and discomfort. c. You believe this would not have happened if you had not been alone? d. You are right. You should not have been alone on the street at night.

C A reflective communication technique is helpful. Looking at ones role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victims perceived role and interfere with further discussion.

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, Don't touch me! You are so stupid. You will make it worse! Which intervention uses a cognitive technique to help this patient? a. Discontinue the dressing change without comments and leave the room. b. Stop the dressing change, saying, Perhaps you would like to change your own dressing. c. Continue the dressing change, saying, Do you know this dressing change is needed so your wound will not get infected? d. Continue the dressing change, saying, Unfortunately, you have no choice. Your doctor ordered this dressing change.

C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patients anger by belittling or escalating the patients sense of powerlessness.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

A confused older adult patient in a skilled care facility is sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patients action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care workers behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, My parents don't like me. They call me stupid and say I never do anything right. Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

C Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.

C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

A patient is pacing the hall near the nurses station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. Hey, what's going on? b. Please quiet down immediately. c. I'd like to talk with you about how you're feeling right now. d. You must go to your room and try to get control of yourself.

C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patients feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority question? a. Do you drink excessively? b. Did your partner beat you? c. How did this happen to you? d. What did you do to deserve this?

C Obtaining the persons explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or borderline personality disorder.

A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as a difficult person who finds fault with others. The patient verbally abuses nurses for providing poor care. The most likely explanation for this behavior lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm.

C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

C The assessment of physical abuse is supported by the nurses observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by a military attack team d. Completion of alcohol withdrawal and beginning a rehabilitation program

C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability.

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, I dread facing potentially violent patients. Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.

An adult tells the nurse, My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it. Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, I have to go home to cook dinner before my husband arrives from work. To intervene with validation therapy, the nurse should first say: a. You must come away from the door. b. You have been a widow for many years. c. You want to go home to prepare your husbands dinner? d. Was your husband angry if you did not have dinner ready on time?

C Validation therapy meets the patient where she or he is at the moment and acknowledges the patients wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patients feelings.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patients discharge? a. Patient states, I feel safe and entirely relaxed. b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

A rape victim asks an emergency department nurse, Maybe I did something to cause this attack. Was it my fault? Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the persons level of anxiety? a. Weak b. Mild c. Moderate d. Severe

D Anxiety is the result of a personal threat to the victims safety and security. In this case, the persons symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety allow the person to function at a higher level.

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, I can't talk about it. Nothing happened. I have to forget! What is the persons present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

D Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patients statements do not reflect somatic symptoms, repression, or projection.

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

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

A nurse working a rape telephone hotline should focus communication with callers to: a. arrange long-term counseling. b. serve as a sympathetic listener. c. obtain information to relay to the local police. d. explain immediate steps that a victim of rape should take.

D The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

An employee has recently been absent from work on several occasions. Each time, this employee returns to wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurses interview, the employee says, My partner beat me, but it was because there are problems at work. What should the nurses next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

D Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

When a patients aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patients affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the pre-assaultive phase but is less effective during escalation.

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

D The description of the patients behavior shows the classic signs of someone whose potential for aggression is increasing.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options

Information from a patients record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. substance abuse.

D The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.