Violent

C

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? A: The family's feelings about the attack B: The client's feelings of social isolation C: The client's ability to cope with the situation D: Disturbance in the client's thought processes

A

What important intervention should be included in the nursing care provided immediately after a sexual assault? A: Obtaining the assault history from the client B: Informing the police before the client is examined C: Having the client void a clean-catch urine specimen D: Testing the client's urine for seminal alkaline phosphatase

B, C

What behavioral findings correspond to intimate partner violence in young adolescents? Select all that apply. A: Sexually acting out B: Attempting suicide C: Pattern of substance abuse D: Fear of certain people or places E: Preoccupation with others or one's own genitals

A, D, E, F

When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply. A: Victim of family violence B: Limited or strained family finances C: Member of a single-parent household D: Dependence on alcohol, drugs, or both E: Uncertainty related to sexual orientation F: Repeated demonstration of poor impulse control

A

A young woman tells the nurse, "My partner prevents me from taking my medications." What should the nurse do to deal with the situation? A: Conduct an interview with the client alone, when the partner is not around. B: Notify the primary healthcare provider to conduct an interview with the client. C: Collaborate with multiple community resources to obtain adequate health care. D: Evaluate the client's and the family's cultural beliefs, values, and practices to determine their specific needs.

B

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? A: Asking that the prescription indicate the type of restraint B: Recognizing that PRN prescriptions for restraints are unacceptable C: Implementing the restraint prescription when the client begins to act out D: Ensuring that the entire staff is aware of the prescription for the restraints

C

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? A: It will help the nursing staff give legal advice and provide counseling. B: Talking about the assault will help the client see how her behavior may have led to the event. C: It will let the victim put the event in better perspective and help begin the resolution process. D: Discussing the details will keep the victim from concealing the intimate happenings during the assault.

D

A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior? A: Being assertive B: Responding early C: Providing choices D: Teaching relaxation

B, D

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. A: "Kids have to learn to be careful on the stairs." B: "Every time I turn around the kid is falling over something." C: "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." D: "I can't understand it. This child didn't have a problem using the stairs without my help before this." E: "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."

C

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? A: "Why did you fall down the stairs?" B: "Did you really fall down those stairs?" C: "Show me how you fell down the stairs." D: "Your mommy must have told you to say you fell down the stairs."

C

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? A: Reserve an operating room. B: Organize equipment for a tracheotomy. C: Prepare equipment for chest tube insertion(胸管放置). D: Arrange for a portable chest x-ray examination

B

Which intervention will the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering(v. 引起) phase of an assault cycle? A: Discuss alternative behaviors to substitute for aggression. B: Provide the child with a quiet, low-stimulus environment. C: Speak to the child in a calm but firm manner. D: Administer medication as needed (PRN) to facilitate de-escalation

C, D, E

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Select all that apply. A: Presence of hyoid bone damage B: Presence of cognitive impairment C: Presence of burns from cigarettes D: Presence of foreign bodies in the rectum E: Presence of unexplained bruises on the wrist(s)

C

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? A: The rape victim was using opioids. B: The rape victim was using hallucinogens. C: The rape victim was drugged with flunitrazepam. D: The rape victim was under the influence of alcohol.

D, E

A nurse suspects sexual child abuse in a preschooler who has come for a routine check-up. What physical findings lead to the nurse's suspicion? Select all that apply. A: The nurse finds signs of immersion burns. B: The nurse finds hematomas and bruises at various stages of resolution. C: The nurse finds injuries and trauma inconsistent with reported cause. D: The nurse finds that the preschooler has difficulty walking and sitting. E: The nurse finds that the child has pain, itching, or unusual odor in genital area.

D

Which infection is identified by evaluating the vaginal specimen of an adolescent client who sustained a sexual assault? A: Syphilis B: Chlamydia C: Hepatitis B D: Trichomoniasis

C, E

A nurse provides crisis intervention for a client who recently left her husband because of physical abuse. Which client behaviors indicate to the nurse that the therapy has been successful? Select all that apply. A: Is able to cry B: Sleeps half the day C: Utilizes healthier coping skills D: Refuses a referral to support services E: Describes the current situation realistically

C, D

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply. A: Bedwetting B: Thumb-sucking C: Difficulty consoling D: Underdevelopment for age E: Demands for physical closeness

C

A nurse may best assist abusive parents in altering behavior toward their abused 2-year-old child by helping them do what? A: Recognize what behavior is appropriate for a toddler. B: Learn appropriate ways of punishing a toddler's inappropriate behavior. C: Identify the specific ways in which the toddler's behavior provokes frustration. D: Ignore the toddler's negative nondestructive behavior while supporting acceptable behavior.

B

A nurse on the pediatric unit is assigned to care for a 2-year-old child with a history of physical abuse. What does the nurse expect the child to do? A: Smile readily at anyone who enters the room. B: Be wary(adj. 谨慎的) of physical contact initiated by anyone. C: Begin to scream when the nurse nears the bedside. D:Pay little attention to the nurse standing at the bedside

A, C, D

A nurse caring for a pregnant client at 28 weeks' gestation and her partner suspects intimate partner violence. Which assessments support this suspicion? Select all that apply. A: The woman has injuries to the breasts and abdomen. B: The partner refuses to come into the examination room. C: The partner answers questions that are asked of the woman. D: The woman has visited the clinic several times in the last month. E: The partner is excessively attentive while the health history is being taken

D

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? A: The child may attempt suicide. B: The child may be verbally aggressive. C: The child may have stress-related concerns. D: The child may show fear of certain people or places.

C

A nurse has learned that infants born to very young mothers are at risk for neglect or abuse, primarily because of what characteristic typical of adolescent mothers? A: Did not plan for her pregnancy B: Cannot anticipate her baby's needs C: Is involved in seeking her own identity D: Becomes resentful of the need to give constant care to the baby

A, B, E

A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old child, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply. A: By denying beating the child B: By avoiding talking about the situation C: By asking where the other three children are D: By expressing excessive concern for the child E: By exhibiting an emotional response that is inconsistent with the degree of injury

B, C

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. A: Limiting contact with the abuser B: Determining a safe place to go in an emergency C: Memorizing the domestic violence hotline number D: Obtaining a bank loan to finance leaving the abuser E: Arranging for a family member to assist her in leaving