Violence NCO
A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client? 1. Reserve an operating room. 2. Organize equipment for a tracheotomy. 3. Prepare equipment for chest tube insertion. 4. Arrange for a portable chest x-ray examination
3. prepare equipment for chest tube insertion Rationale: The priority is to reinflate the lungs and stabilize the client's respiratory status. Reserving an operating room may be necessary later but is premature at this time. Organizing equipment for a tracheotomy is unnecessary; an endotracheal tube should be used for maintenance of the airway if necessary. Arranging for a portable chest x-ray examination is not the priority at this time; this may be done later.
A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action? 1. Sitting quietly with the client 2. Encouraging the client to play video games 3. Introducing the client to several other clients 4. Assigning a staff member to supervise the client
4. assigning a staff member to supervise the client Rationale: Assigning a staff member to supervise the client will enable the staff member to respond quickly to any escalation in the client's mood or behavior. Sitting quietly with the client may put the nurse at risk, because it may actually make the client more anxious and precipitate violence. The client is too anxious to concentrate on a game or to interact with other people.
client going through an emotional disturbance often gets violent and tries to commit suicide. Which care system is best for the client? 1. Rehabilitation 2. Psychiatric facility 3. Intensive care unit 4. Extended-care facility
2. psychiatric facility Rationale: Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. Clients require rehabilitation after a physical or mental illness, injury, or chemical addiction. An intensive care unit (ICU) is a hospital unit where clients receive close monitoring and intensive medical care. An extended-care facility provides intermediate medical, nursing, or custodial care for clients either recovering from acute illnesses or suffering from chronic illnesses or disabilities.
A nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurse's priority during assessment? 1. The family's feelings about the attack 2. The client's feelings of social isolation 3. The client's ability to cope with the situation 4. Disturbance in the client's thought processes
3. the client's ability to cope with the situation Rationale: The situation is so traumatic that the individual may be unable to use past coping behaviors to comprehend what has occurred. Assessing emotions that occur in response to news of the attack will occur later. The client should be the focus of care at this time. Social isolation is not an immediate concern. Coping skills, not thought processes, are challenged at this time
The husband of a woman who has been sexually assaulted arrives at the hospital after being called by the police. After reassuring him about his wife's condition, the nurse should give priority to what? 1. Arranging for the rape counselor to meet with the wife 2. Discussing with him his own feelings about the situation 3. Helping him understand how his wife feels about the situation 4. Making him comfortable until the practitioner has finished examining his wife
2. discussing with him his own feelings about the situation Rationale: Partners may themselves feel angry and abused; these feelings should be quickly and openly discussed. Arranging for the rape counselor to meet with the wife should not be done yet; rape counselors work with the victim and partner together. The partner's feelings must be resolved before the partner can help the client, and the nurse may not fully know the wife's feelings. Making him comfortable until the practitioner has finished examining his wife may be reassuring, but it leaves the partner alone to deal with his feelings.
A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. 1. Limiting contact with the abuser 2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number 4. Obtaining a bank loan to finance leaving the abuser 5. Arranging for a family member to assist her in leaving
2. determining a safe place to go in an emergency 3. memorizing the domestic violence hotline number Rationale: It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.
A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? 1. Asking that the prescription indicate the type of restraint 2. Recognizing that PRN prescriptions for restraints are unacceptable 3. Implementing the restraint prescription when the client begins to act out 4. Ensuring that the entire staff is aware of the prescription for the restraints
2. recognizing that PRN prescriptions for restraints are unacceptable Rationale: A new prescription must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary prescription. Less restrictive interventions should be used when the client begins to act out; restraints are used as a last resort.
A client comes to a trauma center reporting that she has been raped. She is disheveled, pale, and staring blankly. The nurse asks the client to describe what happened. What is the nurse's rationale for doing this? 1. It will help the nursing staff give legal advice and provide counseling. 2. Talking about the assault will help the client see how her behavior may have led to the event. 3. It will let the victim put the event in better perspective and help begin the resolution process. 4. Discussing the details will keep the victim from concealing the intimate happenings during the assault.
3. it will let the victim put the event in better perspective and help begin the resolution process Rationale: Talking about what actually happened helps the client sort out the truth from confused thoughts and helps the client begin to accept what has happened as a part of her history. Legal counsel should come from a legal authority, not the nurse; the victim should be told of the legal services available. Sexual assaults are often planned. They are violent acts, and the perpetrators are responsible for their behavior. If the client does not want to discuss intimate details, this wish should be respected.
An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam. The nurse knows that flunitrazepam is often used for what? 1. As a date rape drug 2. To control symptoms of psychosis 3. To control symptoms of bipolar mania 4. To treat hangover symptoms after excessive alcohol consumption
1. as a date rape drug Rationale: Flunitrazepam, illegal in the United States, has been used in date rapes; the victim is attacked after consuming a drink spiked with the drug. Flunitrazepam is not used to treat psychosis, mania, or hangover symptoms.
A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. What does the nurse suspect as the cause of the fracture? 1. Child abuse 2. Vitamin D deficiency 3. Osteogenesis imperfecta 4. Inadequate calcium intake
1. child abuse Rationale: Injuries in various stages of healing are the classic sign of child abuse. Vitamin D deficiency, osteogenesis imperfecta, and inadequate calcium intake may all be investigated after child abuse has been ruled out.
Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed? 1. Grief 2. Family 3. Psychoanalytical 4. Psychoeducational
1. grief Rationale: Grief therapy provides guidance as one completes the tasks of successful mourning; its goal is to prevent unresolved and dysfunctional grief. Family therapy focuses on the family as a system rather than on just one individual's problem; the goals of family therapy are to foster the self-worth of all members, promote clear and honest communication among members, create guidelines for interaction that are realistic and flexible, and link individuals and family with society in ways that are open and hopeful. No data in the scenario indicate that the family became dysfunctional after the tragedy. Psychoanalytic therapy is generally not used to explore unresolved grief. Psychoanalysis helps the individual become aware of repressed emotional conflicts, analyze their origin, and, through the process of insight, bring them into consciousness, so maladaptive behavior can be altered. Psychoeducational therapy is focused on teaching clients and family members about disorders, treatments, and resources with the goal of empowering them to participate in their own care once they have the knowledge. No evidence in the scenario indicates that the families need psychoeducational therapy.
A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent? 1. "Tell me again how your child fell down the stairs." 2. "Your child says the stairs did not cause this injury." 3. "Did you do anything to cause this injury to your child?" 4. "Why don't you tell me what really happened to your child?"
1. tell me again how your child fell down the stairs Rationale: The nurse needs additional information to investigate the contradictory responses. The response "Your child says the stairs did not cause this injury" will put the parent on the defensive and may increase the child's risk for additional abuse. The response "Did you do anything to cause this injury to your child?" requires a yes or no response and will limit further discussion; it may also precipitate a defensive response. The response "Why don't you tell me what really happened to your child?" is judgmental, will interfere with further communication, and may precipitate a defensive response.
A nurse is working with a child who was physically abused by a parent. What is the most important goal for this family? 1. The child will live in a safe environment. 2. The parents will use verbal discipline effectively. 3. The family will feel comfortable in its relationship with the counselor. 4. The parents will gain an understanding of their abusive behavior patterns.
1. the child will live in a safe environment Rationale: The most important goal and top priority is to ensure the safety of the child. Once this is ensured, other goals can be identified and fulfilled, including the parents using verbal discipline effectively, the family feeling comfortable in its relationship with the counselor, and the parents gaining an understanding of their abusive behavior patterns.
A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon? 1. Tolerance 2. Habituation 3. Physical addiction 4. Psychological dependence
1. tolerance Rationale: Tolerance is a phenomenon that occurs in addicted individuals in which increasing amounts of the drug of addiction are needed to satisfy need; the client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.
When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply. 1. Victim of family violence 2. Limited or strained family finances 3. Member of a single-parent household 4. Dependence on alcohol, drugs, or both 5. Uncertainty related to sexual orientation 6. Repeated demonstration of poor impulse control
1. victim of family violence 4. dependence on alcohol, drugs, or both 5. uncertainty related to sexual orientation 6. repeated demonstration of poor impulse control Rationale: Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.
A registered nurse is teaching a nursing student about sexual assault in teenagers. Which statement made by the nursing student indicates a need for further education? Select all that apply. 1. "Sexual intercourse that occurs by physical force is referred to as rape." 2. "A sexual assault committed on a person above the age of consent is called statutory rape." 3. "A medical examination of rape victims provides evidence of penetration and ejaculation." 4. "A rape that occurs when the assailant is 18 years of age or older is referred to as acquaintance rape." 5. "Inappropriate sexual activity such as inappropriate touching and psychological coercion in sexual acts is referred to as sexual assault."
2. a sexual assault committed on a person above the age of consent is called statutory rape 4. a rape that occurs when the assailant is 18 years of age or older is referred to as acquaintance rape Rationale: A rape that occurs when the assailant is above 18 years of age and the victim is under 18 years of age is referred to as statutory rape. A rape that occurs when the assailant and victim know each other is referred to as acquaintance rape. Forced sexual intercourse that occurs by physical force or psychological coercion is referred to as rape. Penetration, ejaculation, and the use of force are clinical manifestations of rape. Inappropriate touching and inappropriate sexual activity is referred to as sexual assault.
A client who is a regular user of cocaine is admitted to a rehabilitation facility. Which common side effects of regular cocaine use should the nurse expect when assessing this client? 1. Nausea, fatigue, and extreme hunger 2. Anxiety, dysphoria, and extreme suspicion 3. Seizures, hoarseness, and electrolyte imbalance 4. Lethargy, sexual arousal, and hormone imbalance
2. anxiety, dysphoria, and extreme suspicion Rationale: Stimulating the central nervous system with cocaine most commonly causes anxiety, dysphoria, and extreme suspicion, which can progress to fear, hallucinations, paranoid delusions, and violent behavior. Nausea is not a side effect. Euphoria, rather than fatigue, and loss of appetite, rather than hunger, are side effects. Seizures, hoarseness, and electrolyte imbalance are not common side effects of cocaine use. An increase in energy, rather than lethargy, occurs. Some cocaine users believe that the drug maximizes sexual experiences, but there is no documentation of this physiological response. Hormone imbalances are not common side effects.
A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next? 1. Continue the unit's activities as if nothing has happened. 2. Arrange a unit meeting to discuss what has just happened. 3. Refocus clients' negative comments to more positive topics. 4. Have a private talk with the clients who cried and started to pace.
2. arrange a unit meeting to discuss what has just happened Rationale: Arranging a unit meeting to discuss what has just happened provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears; an open expression of feelings allows the nurse to address clients' fears and provide reassurance. Ignoring the situation denies reality and may precipitate or reinforce feelings of vulnerability and fear in the other clients. Refocusing clients' negative comments to more positive topics denies clients' concerns and could increase their anxiety and fear. Having a private talk with the clients who cried or started to pace may meet the needs of these two clients but ignores the needs of the other clients.
A 2.5-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? Select all that apply. 1. "Kids have to learn to be careful on the stairs." 2. "Every time I turn around the kid is falling over something." 3. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." 4. "I can't understand it. This child didn't have a problem using the stairs without my help before this." 5. "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid."
2. every time i turn around the kid is falling over something 4. i can't understand it. this child didn't have a problem using the stairs without my help before this Rationale: Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. Toddlers generally need supervision and some assistance when climbing stairs, but abusive parents have little understanding of toddlers' abilities. Although "Kids have to learn to be careful on the stairs" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs" is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. Although "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people usually do not have an understanding of children's needs in relation to growth and development.
A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? 1. "She must not have the financial resources to leave her husband." 2. "Most women try to leave about six times before they are successful." 3. "There's nothing the staff can do; people are free to choose their own lives." 4. "These women should be told how stupid they are to stay in that kind of situation."
2. most women try to leave about six times before they are successful Rationale: Nurses who work with victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to leave abusive relationships. It may or may not be true that the client does not have the financial resources to leave her husband; there is not enough information to support this conclusion. The staff can encourage the woman to make plans for addressing various potential events and provide information about social services and telephone help lines. Shaming women in this position will simply make them less likely to seek help.
Which intervention will the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering phase of an assault cycle? 1. Discuss alternative behaviors to substitute for aggression. 2. Provide the child with a quiet, low-stimulus environment. 3. Speak to the child in a calm but firm manner. 4. Administer medication as needed (PRN) to facilitate de-escalation.
2. provide the child with a quiet, low-stimulus environment Rationale: In the triggering phase, the client's behavior is nonthreatening and poses no danger to others. Minimizing environmental stimuli and providing a calm, nonthreatening environment likely will serve to help the client de-escalate and regain control. Discussion of substitute behaviors is effective only once the crisis is over (postcrisis phase). As the client escalates, the nurse needs to begin to assume control by presenting a calm but firm tone of voice and demeanor. It is at this time that appropriate oral PRN medications may be helpful.
A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? 1. Range of expressed anger 2. Extent of orientation to reality 3. Degree of control over the behavior 4. Determination of whether the anger is justified
3. degree of control over the behavior Rationale: Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.
When a diagnosis of child abuse is established, what is the priority of nursing care? 1. Promoting bonding with the child 2. Staying with the parents while they visit 3. Protecting the total well-being of the child 4. Teaching methods of discipline to the parents
3. protecting the total well-being of the child Rationale: Management of the abused child places protection of the child's total being above consideration of parents' rights or wishes. Protecting the child, not promotion of parental attachment, is the priority at this time. Supervision may be necessary, but it is only part of maintaining the child's well-being. Teaching methods of discipline is not appropriate at this time.
A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? 1. "Why did you fall down the stairs?" 2. "Did you really fall down those stairs?" 3. "Show me how you fell down the stairs." 4. "Your mommy must have told you to say you fell down the stairs."
3. show me how you fell down the stairs Rationale: The response "Show me how you fell down the stairs" will allow the child to show what happened; it removes the pressure of verbalization. Children have difficulty answering "why" questions; asking why the child fell may add to the guilty feelings of the abused child. Asking, "Did you really fall down those stairs?" will confuse the child because it might become necessary to verify a lie. The response "Your mommy must have told you to say you fell down the stairs" will confuse the child because of his or her dependence on the mother; the child may be afraid of contradicting the mother.
A nurse in the emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation should prompt the nurse to assess the child for abuse? 1. The child has Mongolian spots on the back. 2. The child belongs to a single-parent family. 3. The child has received care for injuries twice earlier. 4. The child and parent narrate the same story about the injury.
3. the child has received care for injuries twice earlier Rationale: The nurse should assess the child for abuse if the child has received care for injuries on two earlier occasions. Frequent emergency visits for injuries should prompt the nurse to further investigate the case. Mongolian spots are normal variants of skin coloration obtained at birth and do not need further evaluation. A single-parent home does not indicate that the child is a victim of abuse. The nurse need not assess the child for abuse if both the parent and the child narrate the same story.
While questioning a rape victim, the nurse discovers that the victim does not remember anything related to the assault. Of the following, which is the most probable cause of the victim's memory loss? 1. The rape victim was using opioids. 2. The rape victim was using hallucinogens. 3. The rape victim was drugged with flunitrazepam. 4. The rape victim was under the influence of alcohol.
3. the rape victim was drugged with flunitrazepam Rationale: Flunitrazepam, also known as Rohypnol and the "date rape drug," is a hypnotic drug that produces prolonged sedation and short-term memory loss. Opioids produce a state of euphoria by removing painful feelings and creating a pleasurable experience and a sense of success, accompanied by clouding of the consciousness and a dream-like state. Hallucinogens are drugs that produce vivid hallucinations and euphoria. Alcohol is a depressant that reduces inhibitions against aggression and sexual acting out. While opioids, hallucinogens, and alcohol may alter memory, Rohypnol is the most likely to cause short-term amnesia.
Client Documentation: The client is pacing, making angry gestures and swearing loudly. When asked to discuss the reason for the aggressive, angry behavior, he answers by stating, "She's a horrible wife and a terrible mother to our kids. She abuses more drugs than I ever did and she has ruined our lives. I'm going to give her what she deserves when I get out of here." Client responds well to open-ended questions that encouraged him to discuss his feelings. After 30 minutes of one-on-one communication, the client has de-escalated his anger and is quietly resting in his room. A client admitted for substance abuse detoxification is displaying severe anger toward his spouse. In light of this information, how effectively does the nurse manager determine that the situation was handled? 1. Appropriately, because the client expressed his feelings and is now calm 2. Inappropriately, because the client was allowed to monopolize the nurse's attention for 30 minutes 3. Appropriately, because the nurse used therapeutic communication techniques to deescalate the client's behavior 4. Inappropriately, because the nurse failed to effectively address the client's threat of physical harm to his wife
4. inappropriately because the nurse failed to effectively address the client's threat of physical harm to his wife Rationale: Threatening physical harm requires notification of the appropriate individuals about any viable threat. This documentation fails to address such an intervention by the nurse. Deescalation is a desirable outcome, and therapeutic communication is a vital tool in addressing the client's anger, but the major safety issue cannot be left unaddressed. Communicating with the nurse for an extended period for the purpose of deescalating anger is not inappropriate.
During a nurse's interview with a client who has been sexually assaulted, the woman states that she should have fought back. What is the most therapeutic response by the nurse? 1. "You're feeling guilty about submitting." 2. "You may have submitted, but you had few options." 3. "It's over, so let's not explore what you could have done." 4. "It's hard to know, but what's important is that you're alive."
4. it's hard to know, but what's important is that you're alive Rationale: Whatever action the client took to save her life was the right action; the statement "It's hard to know, but what's important is that you're alive" supports the woman. The response "You are feeling guilty about submitting" is not therapeutic; the word "submit" in any form is emotionally charged and increases feelings of guilt. The response "You may have submitted, but you had few options" is not therapeutic; the word "submit" in any form is emotionally charged and increases feelings of guilt. The response "It's over, so let's not explore what you could have done" leaves the client with the thought that she could have done something more to prevent the attack.
A nurse educates the mother of a four-year-old child about sexual abuse. What behavioral finding explained by the nurse signifies that the child may be a victim of child abuse? 1. The child may attempt suicide. 2. The child may be verbally aggressive. 3. The child may have stress-related concerns. 4. The child may show fear of certain people or places.
4. the child may show fear of certain people or places Rationale: A sexually abused child may show fear of certain people or places. Attempting suicide is observed in adolescents or adults who are being abused. Combative, verbally aggressive behavior can be appreciated in older adults who are sexually abused. Stress-related concerns are unrelated to sexual abuse.
Which infection is identified by evaluating the vaginal specimen of an adolescent client who sustained a sexual assault? 1. Syphilis 2. Chlamydia 3. Hepatitis B 4. Trichomoniasis
4. trichomoniasis Rationale: Trichomoniasis is detected by evaluating the specimen of a vaginal swab. Nucleic acid amplified testing (NAATs) is used to check for chlamydial and gonorrheal infections. Serum evaluation will reveal syphilis and hepatitis infections.