Violence/Trauma
11) Which individual has the highest risk of developing PTSD? A) Victim of assault B) Natural disaster survivor C) Motor vehicle crash survivor D) Military veteran
Answer: D
5) The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is present? A) Call the police to have the spouse arrested for assault. B) Refuse to permit the spouse to visit with the client. C) Call security to have the spouse removed. D) Ask the client if there is anything that is needed at this time.
Answer: D
4) The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client? A) Assist the client to devise a safety or escape plan. B) Encourage the client to take charge of the situation. C) Offer to contact outpatient services if the client promises not to return home after discharge. D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A
9) Which type of rape often involves the use of date rape drugs? A) Acquaintance rape B) Marital rape C) Anal rape D) Gang rape
Answer: A
6) The nurse working in the emergency department is aware that rape victims initially exhibit which emotions? Select all that apply. A) Shock B) Disbelief C) Anger D) Self-blame E) Humiliation
Answer: A, B
1) The nurse is caring for a victim of rape. Which interventions should the nurse include in the client's plan of care? Select all that apply. A) Notifying an attorney for the client B) Supporting the victim during the examination C) Identifying the individual who committed the rape D) Treating acute injuries E) Providing referrals for follow-up care
Answer: B, D, E
12) The nurse is preparing to teach a class about date rape to a group of college-age students. When discussing date rape drugs, which method of prevention should the nurse include in her presentation? A) Never leave a location with a friend. B) Only accept premade drinks from someone you know. C) Never leave your drink unattended. D) Only consume drinks handed to you directly by the bartender or a waitress.
Answer: C
4) A client is admitted to the emergency department with an incomplete spinal cord injury after a fall from a roof. Which prescription does the nurse anticipate to decrease inflammation and nerve damage? A) Hydrocodone (Vicodin) B) Ibuprofen (Motrin) C) Methylprednisolone (Medrol) D) Xylocaine (Lidocaine)
Answer: C
4) A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is the priority for this client? A) Fear B) Anxiety C) Post-Trauma Syndrome D) Ineffective Coping
Answer: C
11) Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain? A) Ultrasound B) X-ray C) MRI D) Blood test
Answer: A
13) The nurse is assessing a 4-year-old child. Which assessment finding indicates to the nurse that the child might have suffered a traumatic event? A) The child refuses to talk or answer questions when previously the child chatted constantly. B) The child draws pictures of family when previously the child drew pictures of animals. C) The child complains of a stomachache and has a fever. D) The child plays quietly in a corner when previously the child sat on his mother's lap.
Answer: A
3) A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate? A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem
Answer: A
4) After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next? A) Conducting a team assessment B) Medicating for anxiety as prescribed C) Notifying the police D) Treating the injuries
Answer: A
7) A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted syphilis. Which prescription does the nurse anticipate for this client? A) Penicillin B) Ceftriaxone and azithromycin C) Tinidazole D) Doxycycline
Answer: A
6) An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply. A) Poor hygiene B) Dehydration C) Intracranial trauma D) Fecal impaction E) Dislocations
Answer: A, B, D, E
8) The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply. A) Involvement in the community B) Participation in family activities C) Residing in an impoverished community D) Academic failures at a young age E) Success in school
Answer: A, B, E
3) A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply. A) Difficulty sleeping B) Hypovigilance C) Alcohol abuse D) Aggressive behavior E) Hair pulling
Answer: A, C, D
7) What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply. A) Airway maintenance B) Obtaining medical history C) Ventilation assistance D) Hemorrhage control E) Hypothermia prevention
Answer: A, C, D, E
8) A client is brought into the emergency department after being assaulted. The provider suspects that the client has a spinal cord injury. Which diagnostic tests does the nurse anticipate based on the data collected? Select all that apply. A) Computed tomography (CT) scan B) X-ray C) Ultrasound D) Magnetic resonance imaging (MRI) E) Positron emission tomography (PET) scan
Answer: A, D
2) The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply. A) Observed family member being raped and murdered B) Restores antique automobiles as a hobby C) Lives with spouse and has a garden D) Has a history of anxiety disorder E) Recently terminated from employment
Answer: A, D, E
3) The nurse is providing care for a client who was the victim of sexual abuse 8 months ago. Which ongoing, long-term treatment goals are appropriate? Select all that apply. A) The client's symptoms of anxiety and fear will decrease. B) The client will involve significant others in the treatment plan. C) The client will be able to verbalize legal rights. D) The client will establish rapport and build a trusting nurse—client relationship. E) The client will learn how to reconnect with others.
Answer: A, E
1) During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the client's behavior? A) The client thought there was an earthquake. B) The client was reacting to the loud noise as a form of a flashback. C) The client wanted to check the cause of the loud noise. D) The client thought the assessment was concluded.
Answer: B
10) A client lost consciousness after being hit by a falling piece of equipment on a work site. What type of injury should the nurse assess this client for as the highest priority? A) Fractured bones B) Traumatic brain injury C) Whiplash D) Spinal cord injury
Answer: B
10) The nurse is caring for a client who has a history of being physically and sexually abused as a child, and his father abandoned the family when he was 7 years old. The nurse recognizes that this increases the client's risk of becoming a perpetrator of rape because of which type of risk factors? A) Individual B) Relationship C) Community D) Societal
Answer: B
10) What type of communication should the nurse employ when caring for a client who has suffered trauma? A) Assertive communication B) Therapeutic communication C) Passive communication D) Aggressive communication
Answer: B
11) A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client's plan of care before discharge? A) Help the client find a new long-term care facility. B) Help the client create a post-discharge safety plan. C) Help the client find a lawyer to sue the long-term care facility. D) Help the client understand the warning signs of suicide
Answer: B
11) If a pregnant woman sustains multisystem trauma, in which order should assessment occur? A) Primary assessment of the mother, secondary assessment of the mother, primary assessment of the fetus B) Primary assessment of the mother, primary assessment of the fetus, secondary assessment of the mother C) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the mother D) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the fetus
Answer: B
11) The nurse is caring for several clients in the emergency department. Which individual is a victim of community violence? A) A 32-year-old woman who was beaten by her spouse B) A 20-year-old man who was shot during a gang dispute C) A 6-month-old girl who was abused by her mother D) A 76-year-old man who was neglected at a care facility
Answer: B
14) The nurse is assessing two clients: a 23-year-old man who recently returned from overseas deployment with the military and a 68-year-old man who served in the military during the Vietnam War. Both clients have been diagnosed with posttraumatic stress disorder (PTSD). Which statement did the nurse likely record from the 68-year-old man? A) "I startle at every sudden noise I hear, whether it is loud or quiet." B) "I haven't had much of an appetite lately, and I keep forgetting important things." C) "I just want to go out and hit someone." D) "I feel so guilty that I came home and three of my good buddies didn't."
Answer: B
2) The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. Which is an appropriate client goal for the nurse to include in the plan of care? A) The client will have adequate urine output. B) The client will regain mobility. C) The client will participate in self-care activities. D) The client will be discharged to home.
Answer: B
5) A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective? A) "Everyone knows what my problems are, and there is nothing I can do about it." B) "I am functioning fine now but I know that when problems come up again, I will ask for help." C) "My friends tell me that I have improved so this is a good time to stop." D) "It is so draining to deal with the same painful issues all of the time."
Answer: B
5) The nurse at a local hospital is conducting a safety workshop for expectant parents addressing newborn injury prevention and car seat safety. Which statement made by a parent indicates a need for further teaching? A) "My newborn should be in a car safety seat every time he is in the car." B) "My baby can ride facing forward as long as he is in a convertible car seat suitable for an infant." C) "My newborn should ride in a rear-facing car seat." D) "Never place a rear-facing car safety seat in the front seat with an active passenger air bag."
Answer: B
5) The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago. Which should the nurse include in the client's plan of care? A) Guidelines on conducting activities of daily living B) Information on the treatments available C) Referral to local employment agency D) Information on the need for adequate exercise
Answer: B
8) A client is admitted with a diagnosis of posttraumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, which medication prescription does the nurse anticipate for this client? A) Propranolol (Inderal) B) Prazosin (Minipress) C) Risperidone (Risperdal) D) Fluvoxamine (Luvox)
Answer: B
1) A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply. A) Confusion B) Missing teeth C) Apprehension when other children cry D) Abrasions to the mouth, lips, and genitalia E) Dehydration
Answer: B, C, D
4) A client recovering from a rape tells the nurse that flashbacks do occur but can be managed. Which techniques should the nurse suggest to the client for managing flashbacks about the event? Select all that apply. A) Restoring personal choice B) Deep breathing C) Muscle relaxation D) Problem solving E) Guided imagery
Answer: B, C, E
6) The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply. A) The client takes a sedative at least four times a day. B) The client has been sleeping throughout the night. C) The client keeps all of the lights on at home. D) The client verbalizes future plans with family and friends. E) The client will not enter a car with fewer than three people.
Answer: B, D
1) An older adult man is transported to the emergency department after a motor vehicle crash. Which risk factors for the older adult could have contributed to the crash? Select all that apply. A) Unsafe driving practices B) Preexisting health conditions C) Speeding D) Texting E) Reduced sensory perception
Answer: B, E
7) Which nursing interventions would be appropriate for a client demonstrating extreme anxiety related to posttraumatic stress disorder (PTSD)? Select all that apply. A) Encourage the client to discuss what caused the syndrome to develop. B) Provide a calm, quiet environment. C) Give the client paperwork to complete while waiting to be assessed. D) Ask the client what is causing the anxiety. E) Reassure the client that the environment is safe.
Answer: B, E
2) A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this data? A) A protective factor B) A risk factor C) A vulnerability factor D) A precipitating factor
Answer: C
2) A client, who was raped and refuses to see any male healthcare providers, tells the nurse that she had an "incident" that she does not want to talk about, and wants a bed by the door. Which nursing diagnosis is appropriate for the client? A) Relocation Stress Syndrome B) Readiness for Enhanced Power C) Rape-Trauma Syndrome D) Acute Confusion
Answer: C
5) A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate? A) "The baby could always be given up for adoption." B) "You will not know for sure for at least a few more days." C) "Emergency contraception is available to prevent pregnancy." D) "Are you sure the rapist did not use a condom?"
Answer: C
6) A nurse is developing a plan of care for a client with traumatic injuries after a natural disaster. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? A) Provide active or passive exercises at least once every 8 hours. B) Encourage coughing, deep breathing, and incentive spirometry. C) Assist the client in turning at least every 2 hours. D) Assist the client in turning at least every 8 hours.
Answer: C
7) The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate? A) Contact adult protective services. B) Call the healthcare provider immediately. C) Assess the client's cultural traditions. D) Contact the client's family.
Answer: C
7) The nurse is discharging a client who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse. The client states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw, we went to Rome." Based on this data, which phase of violence is the client experiencing? A) The tension phase B) The abusive phase C) The honeymoon phase D) The reconciliation phase
Answer: C
8) A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take? A) Discuss what the nurse witnessed with the infant's mother. B) Discuss what the nurse witnessed with the other nurses. C) Report what the nurse witnessed and assessed to the authorities. D) Call security to remove the father from the room.
Answer: C
8) A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted trichomoniasis. Which prescription does the nurse anticipate for this client? A) Penicillin B) Ceftriaxone and azithromycin C) Metronidazole D) Doxycycline
Answer: C
9) A client is brought into the emergency department after being in a motor vehicle crash. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this client? A) Breathing and ventilation B) Circulation with hemorrhage control C) Airway maintenance with cervical spine protection D) Disability and neurologic assessment
Answer: C
9) Which of the following is a common element of abuse experienced by the victim? A) Accidental injury B) Feelings of control C) Humiliation D) Manipulation
Answer: C
6) The nurse is providing care to a child who has suffered abuse. Which nursing actions are appropriate? Select all that apply. A) Ask the child what he did to cause his parents to beat him so badly. B) Tell the child that the individual who hurt them is a bad person. C) Follow protocols for mandatory reporting. D) Remind the child that he did nothing wrong. E) Ask the child what really happened.
Answer: C, D
2) The nurse is providing care for a 2-year-old client. When assessing the client's risk for abuse, which factors increase this client's risk? Select all that apply. A) The child has bruises on the knees and shins. B) The child's parents are married. C) The child is less than 3 years old. D) The child is deaf. E) The child's parents are unemployed and receive medical assistance.
Answer: C, D, E
3) A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply. A) Explore options for self-development. B) Improve quality of life by increasing self-esteem. C) Explore options for help. D) Convey safety. E) Determine immediacy of danger.
Answer: C, D, E
1) A young client is brought into the emergency department by a friend who says the client was "beat up" at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this client? A) The client does not want the individual who did the beating to get in trouble. B) The client does not know his parents. C) The client does not want the school to get in trouble. D) The client is a victim of interpersonal violence.
Answer: D
10) A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD) who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client? A) Disturbed Sleep Pattern B) Post-Trauma Syndrome C) Risk for Other-Directed Violence D) Risk for Self-Directed Violence
Answer: D
12) An individual who has experienced which type of trauma is likely to be most resilient? A) Intimate partner violence B) Bullying C) Rape D) Natural disaster
Answer: D
12) Which form of therapy might be used to help an individual with posttraumatic stress disorder (PTSD) visit the location where a traumatic event occurred? A) Cognitive-behavioral therapy B) Dual attention stimulus therapy C) EMDR therapy D) Exposure therapy
Answer: D
3) A client was admitted to the hospital after a crush injury to the chest. The client sustained multiple rib fractures, a collapsed lung, and several skin abrasions. After the client is stabilized, which nursing intervention would be a priority for this client? A) Monitor urine output. B) Assess vital signs. C) Perform passive range of motion to all extremities. D) Assist to deep breathe and cough every 2 hours.
Answer: D
9) A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the client's plan of care? A) The client will report a reduction in or cessation of nightmares. B) The client will report a decreased perception of anxiety. C) The client will discuss emotions related to traumatic experiences. D) The client will remain free from injury or harm.
Answer: D
10) Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors? A) Social learning theory B) Psychopathology theory C) Neurobiology theory D) Environmental theory
Answer: A
9) Which cause of multisystem trauma is the leading cause of injury death in the United States? A) Poisonings B) Motor vehicle crashes C) Assault D) Natural disasters
Answer: A