OB Chapter 9

A nurse is screening a client for intimate partner violence using indirect questions. Which question would the nurse most likely ask?

"Clients with your injuries are often abused. Is anything like this happening now?" Rational: "Does your partner hit you?" or "Have you ever been or are you now in an abusive relationship?" are direct questions. They are focused and address the topic with the client directly. If that approach feels uncomfortable, indirect questions can be used, such as "We see many clients with injuries or reports like yours, and often they are being abused. Is that what is happening to you?" or "Many people in our community experience abuse from their partners. Is anything like that happening in your life?" With either approach, nurses need to maintain a nonjudgmental acceptance of whatever answers the woman offers.

During a prenatal assessment, the nurse observes that the client is quiet and withdrawn. The client keeps asking if her partner can come into the examination room, because the partner does not like to be kept waiting. Which question would be most important for the nurse to ask before the partner comes into the examination room?

"Do you feel safe in your home?" Rational: Client safety is the priority. Asking if the client feels safe, before the partner is present, is important. Also, the client may be reluctant to answer this question if the partner is present. Feeling safe is a higher priority than gathering specifics about the relationship, such as what occurs when they argue. The other questions can be asked with the partner present, with the client's permission.

While performing an assessment on a female client, the nurse notes signs of sexual assault. When questioned, the client states, "I am married, so I have not been raped or abused." What statement by the nurse is most appropriate?

"If you do not consent, it is still assault when you are married." Rational: A married woman still has to provide consent for sexual activities. Without consent, it is rape or sexual assault for married women, just as it is for single women. The length of the marriage is not relevant to defining intimate partner violence.

The nurse suspects a client is a victim of intimate partner violence (IPV). Which statement by the client supports the nurse's suspicion?

"My spouse refuses to let me go out to find a job." Rational: Financial abuse (preventing one's spouse from going out to find a job) is a form of IPV. Constant complaints about a job, being abusive to animals, and road rage are not indicative of intimate partner violence.

The nurse is teaching a group of nursing students about intimate partner violence. Which statement by the nurse is accurate?

"Power and control are central to the dynamic of intimate partner violence." Rational: Power and control of one partner over the other is the foundation of intimate partner violence. Erratic relationships and vulnerability are not central factors to the dynamic of intimate partner violence. Poor communication, emotional injury, learned helplessness, and social isolation are potential outcomes of being in a relationship where intimate partner violence is present.

The triage nurse receives a phone call from a client stating, "I was just raped and I need help. What should I do?" Which response by the nurse is a priority?

"Tell me if you are in a safe location away from the assailant now." Rational: It is a priority for the nurse to determine the client's safety. After ensuring the client is safe, the nurse would tell the client to come to the emergency department, not a crisis center, prior to bathing or changing clothes. The authorities will be contacted from the emergency department. It is best to obtain evidence and specimens as soon as possible after the attack.

The nursing student is studying violence and mistreatment against the older woman. While researching it, the student learns that laws require health care professionals to report elder or vulnerable person mistreatment. How many states currently have these laws?

50 Rational: All fifty states have laws requiring health care professionals to report elder or vulnerable person mistreatment.

A nurse is caring for a pregnant woman who has multiple bruises in varying stages across her body. Which is the priority nursing action?

Ask if anyone at home has hit or hurt her. Rational: In the case of suspected intimate partner violence, it is best for the nurse to ask direct questions. Asking all women at physical examinations to account for any bruise they have helps detect physical maltreatment. Intimate partner violence is not typically reported by the nurse, but by the adult client. Once the nurse believes abuse is occurring, it is important to give her resources for abuse victims. Referring to counseling may be an option, but it is best to verify first.

A client at 36 weeks' gestation presents in the emergency department with a broken arm. The client states, "I fell while cooking dinner." During the assessment, the nurse notes no prenatal care for this pregnancy, as well as bruises in multiple stages of healing on the client's abdomen, arms, and chest. What action will the nurse perform next?

Ask the client how she acquired the bruises Rational: First, the nurse will ask how the client acquired the multiple bruises. This will provide information on possible violence. The nurse would also notify the health care provider and document the findings. Information would be provided based on the finding of intimate partner violence.

When initiating care for a client suspected of being a victim of human trafficking, what is the nurse's primary responsibility?

Building trust Rational: Building trust is the top priority. Although the other actions are appropriate, they are less achievable without first establishing a trusting relationship with the client.

The nurse is caring for a client who is seeking care after being raped. What is the primary reason the nurse does not leave the client alone during the emergency room stay?

Promotes the client's sense of safety Rational: The nurse's first responsibility is to provide the client a safe environment both physically and emotionally. Staying with the client will help promote a sense of safety. Although the other options may result from the nurse's presence, the primary goal is safety.

The nurse is caring for a client who is a victim of sexual violence. How can the nurse best support the necessary grieving process?

actively listening to the client as he or she talks about the experience Rational: Providing support and allowing the client to grieve for the loss is achieved by listening to and clarifying the reactions to the traumatic event. Although the other actions are appropriate, they are not focused on successful grieving but rather coping with stress and preparing the client to effectively deal with the common complications of this form of trauma.

Which type of elder mistreatment involves harm of self-worth?

emotional Rational: The six types of elder mistreatment are physical (injury by hitting, kicking, pushing, slapping, burning, and so on), sexual (unconsented sexual act), emotional (harm of self-worth or emotional well-being), neglect (failure to meet the older adult's basic needs of shelter, food, and so on), abandonment (leaving an older adult alone and no longer providing care), and financial (illegally misusing money, property, or assets).

The nurse who counsels clients who suffer from intimate partner violence (IPV) understands that IPV can come in which form(s) of abuse? Select all that apply.

emotional abuse physical abuse financial abuse sexual abuse Rational: In a situation with IPV, abusers may use whatever it takes to control a situation—from emotional abuse to physical assault. The different types of IPV include emotional, physical, financial, and sexual abuse. Although a person could put down a partner's religion and/or keep the partner from worshiping, there is not a distinct abuse labeled as spiritual abuse. Rather, the term spiritual abuse (sometimes called religious abuse) is abuse that occurs within the religious organization, such as when a faith leader inflicts abuse on one or more members of the congregation.

The nurse is conducting a class on rape prevention for a group of young adults and is describing the various types of date rape drugs. Which drug would the nurse describe as causing a separation in perception and sensation?

ketamine Rational: Ketamine acts on the central nervous system to separate perception and sensation. Rohypnol produces memory loss for up to 8 hours. GHB produces euphoria, an out-of-body high, sleepiness, increased sex drive, and memory loss. It may cause unconsciousness, depression, and coma. Diazepam is an antianxiety agent that causes sedation, lethargy, mild drowsiness, confusion, and disorientation.

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"My partner tells me that I will be turned into child services for being a bad mother." Rational: The statement about telling child services that the client is a bad mother reflects coercion and threats. The statement about the abuse never happening reflects power and control through minimizing, denying, and blaming. The statement about whom the client can and cannot see reflects power and control through the use of isolation. The statement about the partner being the master of the castle reflects power and control through the use of privilege.

The nurse is asked to provide information for a task force addressing child abuse (child mistreatment) in the community. Which prevention tactics are suggested? Select all that apply.

Develop and teach high school courses on parenting and normal child growth and development. Promote activities that encourage self-esteem in young adults. Role-model for caregivers various behaviors with children that are compassionate, loving, and caring. Educate those who were abused as children, and offer them professional help to break the pattern of violence. Help parents and caregivers find local support in their community. Rational: The nurse is correct to identify areas that may prevent child abuse (child mistreatment) in the community. These tactics include education, role modeling, community support, and ways to improve self-esteem. Incarceration does not prevent abuse and occurs after child abuse (child mistreatment) has occurred.

A client at 34 weeks' gestation comes to the clinic with her partner and reports neck and back pain. During the assessment, the nurse notes multiple contusions in various stages of healing on the client's torso and weight gain of 3 lb (1.36 kg) during the course of the pregnancy. Which action will the nurse take next?

Have the client's partner leave the room during the examination. Rational: The nurse would suspect intimate partner violence (IPV) due to the client's presentation of poor weight gain (should gain 25 to 35 lb/11.5 to 6 kg) during a normal pregnancy, current injuries, and multiple contusions in various stages of healing. When IPV is detected, the nurse should immediately isolate the client to provide privacy during questioning to prevent potential retaliation from the abuser. The client does not present with signs of an eating disorder. However, if IPV is ruled out, this may be further explored. The nurse would notify the health care provider after completing the assessment and admission process. Knowing the client's prior weight gain is not a priority at this time. This can be reviewed last.

An obviously pregnant woman appears for her first prenatal visit. She reports a headache and generalized abdominal pain which has persisted over the past couple months. Which question should the nurse prioritize after determining the client is approximately 24 weeks' gestation, appears nervous, and is reluctant to have a full physical assessment?

"Do you feel safe at home?" Rational: Asking open-ended questions is always the best approach to get the client to open up and provide needed information. This woman may be in a situation with intimate partner violence or have a substance use disorder, which would explain the nervousness, late start on prenatal care, and refusal to allow the nurse to see all of her body; in either situation, she may be trying to hide signs. The other questions are important but are close-ended and would not be a priority if the woman and her unborn fetus were in danger.

The nurse gave a presentation about intimate partner violence (IPV) to a local community group. The nurse determines more teaching is needed when a member makes which statement?

"For the victim's safety, the victim has to learn to be careful to not set off the abuser." Rational: The nurse would provide additional teaching when a member states the victim has to learn how to not set off the abuser. The victim should not be told he or she causes the situations of abuse. Living in a state of fear of retaliation for personal actions is not appropriate. Because IPV can occur to anyone, it is appropriate to observe others for signs and assist them to seek help if possible. Violence occurs in all socioeconomic classes and all genders. Although women are victims of violence more frequently than men, the prevalence of violence among men nonetheless represents a significant public health concern. One out of every four men has experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Alcohol and drugs can make the situation worse.

A client at 27 weeks' gestation comes to the clinic for their first prenatal examination. The client states, "I have been having headaches and abdominal pain for several months." The nurse notes the client appears hurried or nervous and has a contusion on the left jaw. Which question is a priority for the nurse to ask?

"Have you been or are you being abused at home?" Rational: All these questions are important when interviewing a pregnant client; however, the client is presenting with signs of intimate partner violence (IPV). The nurse's priority is client safety. Women are at a higher risk for violence during pregnancy. Asking more directed questions in these areas may be fruitful. The nurse would then ask the client about their previous obstetric history and about any previous births to determine if this is the client's first pregnancy. Asking "why" is not therapeutic and can cause the client to feel judged or threatened. The nurse would also ask about daily fluid consumption after asking about possible abuse.

The nurse is caring for a client who has been a victim of intimate partner violence (IPV) for a few years. The client states, "My partner has been so sweet to me the last few days by telling me how special I am and bringing me flowers. I believe my partner is sorry and will not do this again." How will the nurse respond?

"It may seem better now, but over time, IPV typically becomes accelerated and more dangerous." Rational: The cycle of IPV can cover a long period of time. IPV typically becomes accelerated over time and thus more dangerous. The client needs to know that this is normal behavior for an abuser and does not indicate love or a change. The nurse would respond with facts and not personal beliefs, such as the worth of the client's relationship. The nurse would not state the client is not loved because this could result in decreased trust and respect from the client toward the nurse.

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." Rational: 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. Telling the client to think of the safety of the unborn child does not reflect an understanding of the types of abuse. Continuing with the assessment ignores the potential IPV. Information would be provided after further investigation.

A client tells the nurse "My partner is going to stop drinking, so I know I won't be hit again." What is the nurse's best response?

"Violence is a learned behavior, not caused by alcohol." Rational: Violence is a learned behavior that may be potentiated by drugs and alcohol, but not caused by drugs and alcohol. The nurse should educate the client about the causes of intimate partner violence. The nurse should not provide personal opinions.

Which initial interview technique would be least effective in gathering information from a suspected abuse victim?

Ask the client to strip down and show you where she has been hurt. Rational: When interviewing a suspected abuse victim initially, the nurse needs to be supportive and respectful of her. Always talk to the victim alone and in a private place. Ask simple, direct, open-ended questions that allow the client to describe her experiences. Never imply that the woman is in any way responsible for the abuse by asking questions about why she stays with the abuser or what she did to make him mad. Never ask the client to strip for you to inspect her body initially. The nurse needs to establish a rapport with the woman first so trust can be established.

The nurse is interviewing a client who has experienced intimate partner violence. Which nursing intervention will likely be most effective in assuring the client that the interview will be kept confidential?

Assure the client agrees before any information can be released Rational: Confidentiality, a right of any client, is especially important since the victim might believe that, if the abuse is reported, the abuser will retaliate. Assuring the client that information will not be released without client permission is the most effective means of building trust and encouraging the client to share information. The police will not be made aware of the details without the client first giving permission. Although the other actions are appropriate interventions, they do not directly address the concern that the information may be shared.

A client and partner present in the emergency room. The client has a broken arm and facial bruising. The client states the injuries are the result of tripping into a wall. The nurse suspects intimate partner violence (IPV). Which intervention will the nurse perform first?

Attempt to complete the client's assessment and admission in private. Rational: If the nurse suspects IPV, the nurse should attempt to interview the client in private. Many abusers will not leave their partners for fear of being reported. The nurse should use subtle ways of doing this, such as telling the client a urine specimen is required and showing the client the way to the restroom, providing the nurse and client with some private time. Asking the partner regarding how the injuries were sustained will not help because the partner may not admit culpability. Having authorities remove the partner from the client's room may rouse the suspicions of the partner and cause more abuse for the client once home. Providing the client with material on IPV and safety plans in the presence of the partner may trigger another abusive episode and should be avoided. Precaution should be taken to prevent the abuser from punishing the client when the client returns home.

A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client?

Being nonjudgmental Rational: During the screening process the victim is most likely to be uncomfortable and not want to participate. Victims are concerned about being judged by the interviewer, provoking more violence, and being disappointed by the provider's response to the disclosure. The nurse can best help the victim participate in screening by ensuring confidentiality and being nonjudgmental. There is no guarantee the nurse can assure the woman of help. At best, the nurse can provide information of agencies and services. Having the client be honest about the injuries can cause much distress for the client who may feel it will only lead to more injuries after the partner realizes details have been disclosed. Helping the client find community resources to develop a plan of protection is best done with the social worker and community agencies rather than the emergency room nurse. The nurse should make a referral to the social worker to help with this situation.

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. Rational: 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. Providing the client with information in the presence of the partner is not appropriate. This could subject the client to additional abuse upon leaving the medical facility.

The nurse is caring for a client in an abusive situation. In developing a plan of care, which factors does the nurse consider? Select all that apply.

It often takes several attempts before a woman leaves an abusive situation. Women in abusive relationships usually feel isolated and unsupported. Substance use is a common factor in abusive relationships. Rational: Factors that need to be considered include the following: It often takes several attempts before a woman leaves an abusive situation; women in abusive relationships usually feel isolated and unsupported; and substance use is a common factor in abusive relationships. Economic factors are often a factor because the partner/abuser usually controls the financial resources. Toddlers and preschool-age children can be affected by parental discord and intimate partner violence (physical, emotional, verbal) that takes place in the household.

A pregnant woman comes to the clinic with a head injury. She tells the nurse that her partner came home drunk and she made him angry by not having dinner ready. He lashed out, she got in the way, and her head hit the corner on the table. What action should the nurse take in this situation?

Provide the client with contact information for a 24-hour shelter and social worker on discharge Rational: The nurse should empower the client by making her aware of the resources and options available to her. The client cannot be forced to leave her situation, stay at a friend's home, or to report the abuse.

During the assessment, a client states, "I need something to calm my nerves and help me with sleeping. My spouse will not let me look for a job, and when I need money, I am told I cannot have any since I do not work." Which action by the nurse is most appropriate at this time?

Provide the client with education on intimate partner violence. Rational: The nurse would suspect the client is suffering from financial abuse, which is a form of intimate partner violence (IPV). Financial abuse includes preventing a partner from getting a job, sabotaging a current job, controlling how all money is spent, or failing to contribute financially. The nurse would provide the client education and materials on IPV, specifically financial abuse, and answer any questions the client may have. The nurse would discuss the need for any referrals with the health care provider after completing the client's assessment and determining the level of IPV. If the client states a desire to leave the spouse, the nurse would provide information on resources to assist the client. It is not the nurse's place to determine if it is appropriate for the client to leave a spouse. The nurse would not assist the client in locating an at-home job because this action could intensify the spouse's anger and abuse.

A client who is a rape survivor has appeared to cope very well. However, at a routine visit several months later, the client describes a new onset of nightmares and flashbacks. Which action by the nurse is most appropriate for this client?

Refer the client to a psychologist for psychotherapy treatment. Rational: The client is experiencing signs and symptoms of posttraumatic stress disorder (PTSD), which are experienced by a significant proportion of rape victims. Symptoms can include nightmares, flashbacks, increased emotional arousal, and irritability. The nurse would refer the client for counseling. An SSRI is a type of antidepressant that works by increasing levels of serotonin within the brain. SSRI medications may be used to treat PTSD; however, counseling is recommended before, or at least in conjunction with, beginning medication therapy. A bedtime routine may help with other sleep disturbances; however, this is not the client's complication. The prior event is causing the client's nightmares and flashbacks. A journal may be appropriate for the client but should also be done under the supervision of a counselor/psychologist.

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant Rational: Intimate partner violence (IPV) occurs in both heterosexual as well as same-sex relationships. The nurse needs to be on the lookout for signs of violence when caring for women. It is estimated that 4% to 8% of pregnant women experience abuse during the pregnancy. Signs include a passive or quiet client who may appear unkempt or depressed. The abuser often refuses to leave the client alone with the health care providers and answers questions posed to the mother. The abuser is often overly protective of the client. Consequences of abuse include poor weight gain during the pregnancy, late entry into prenatal care, preterm labor, and fetal death.

A nurse is conducting an awareness session on sexual abuse, and she is explaining the psychological profile of an average abuser. Which trait is often displayed by abusers?

They exhibit antisocial behaviors. Rational: Abusers are most likely to exhibit antisocial behavior or childlike aggression. They use aggression to control their victims. Abusers come from all walks of life; they are not just restricted to low-income groups, nor are they necessarily products of divorced parents. The physical characteristics of the abusers vary, and they are not necessarily physically imposing.

When teaching a group of young adults about the cycle of violence, the nurse would describe which behavior as eventually disappearing as the violence becomes accelerated over time?

apologies for the pain and abuse Rational: As the violence increases in frequency and severity over time, the honeymoon phase gradually shortens and eventually disappears altogether. The abuser no longer feels the need to apologize and indulge in a honeymoon phase as the victim becomes increasingly disempowered by the relationship.

The nurse is educating a group of student nurses on symptoms of sexually abused women. What symptoms will the nurse include in the teaching? Select all that apply.

chronic pelvic pain substance use disorder headaches social withdrawal Rational: Women can experience psychological, physical, and cognitive symptoms that include chronic pelvic pain, substance use disorder, headaches, backaches, withdrawal, anxiety, sexually transmitted infections, pregnancy, depression, guilt, nervousness, and sexual dysfunction. Increased anger is seen in abusers, not their victims.

Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)?

flashbacks Rational: Biologic indicators, such as elevated pulse and blood pressure, sleep and appetite disturbances, exaggerated startle responses, flashbacks, and nightmares, may suggest PTSD or depression. Signs and symptoms of dissociation include memory difficulties, a feeling of unreality about oneself or events, a feeling that a familiar place is strange and unfamiliar, auditory and visual hallucinations, and evidence of having done things without remembering them.

The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases?

hopeless stage Rational: Victims of intimate partner violence appear hopeless. They often exhibit behaviors that demonstrate depression and ambivalence toward their abuser. However, hopelessness is not part of the cycle of violence. With the cycle of violence there is often a pattern: a tension-building phase, a battering incident, and a honeymoon phase.

A nurse is reading a journal article about sexual violence as a public health problem. Which event would the nurse expect to be discussed within the article? Select all that apply.

human trafficking infanticide female genital mutilation bondage incest forced prostitution Rational: Sexual violence is both a public health problem and a human rights violation. Sexual violence includes intimate partner violence, human trafficking, incest, female genital mutilation, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault.

A nurse is describing the cycle of violence to a group at a community clinic. The nurse determines that the attendees have understood the information when they identify which phase as usually lasting the longest?

tension building Rational: The first phase in the cycle of violence, tension building, is usually the longest. Acute battering, in which there is the explosion of violence, and the honeymoon phase are not typically as long.