41 mental health

An adolescent client has recently ended a physically and emotionaly abusive initimate relationship. What nursing assessment question(s) will help identify a commonly associated comorbid mental health problem? Select all that apply.

"How much alcohol do you drink in an average week?" "Do you ever have thoughts of hurting or killing yourself?" "Are your teachers satisfied with the grades you earn in school?" "How would you alter your eating habits in order to lose weight?"

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence?

"I don't know what else I can do to keep him from getting angry at me."

Which statement, made by a nurse who experienced sexual abuse as as a child, demonstrates being best prepared to work with sexual abuse and trauma survivors?

"I've been supported by health care professionals and now I want to support other survivors."

A nurse is working with a client who is a survivor of rape. The client asks the nurse, "It's been 6 months since it happened. Why can't I get back into doing the things I did before?" What is the nurse's best response?

"It can take at least a year or more to get back to where you were before."

The nurse is discussing expectations of raising a child with a pregnant teenager expecting her first baby. The father will not be a participant in the parenting. Which statement made by the expectant mother would be of greatest concern to the nurse?

"My child will love me, unlike my parents ever did."

A client has been in a physically abusive relationship for more than a decade. Which statement best demonstrates that the client understands of how fear can influence a reluctance to leave such a relationship?

"My partner would hunt me down and kill me for sure."

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?

"You have the right to be safe and respected."

The nurse is working at the battered women's shelter with a client who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, "What do you think about that?" The best response by the nurse is,

"You may be in more physical danger after you leave him."

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, "What do you think about that?" Which is the best response by the nurse?

"You may be in more physical danger after you leave him."

The nursing student learning about child abuse correctly identifies which of the following individuals to be at the highest risk for abuse?

5-year-old girl

Approximately what percentage of women rape victims are raped by someone they know?

65%

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what?

70% women and 30% men

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.

A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femur

A nurse is aware of the high incidence of intimate partner violence (IPV) and actively seeks opportunities to screen women for IPV. Which female client represents the best opportunity for assessing for IPV?

A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic

Which type of elder abuse involves leaving an older adult and no longer providing care for the individual?

Abandonment

Which are common characteristics of violent families regardless of the type of abuse that exists? Select all that apply.

Abuse of power and control Alcohol and other drug abuse Intergenerational transmission Social isolation

Which characteristics are found in violent families? Select all that apply.

Abuse of power and control Alcohol use disorder Social isolation

The nurse is assessing an elderly client in the emergency department. There are many bruises present on the client's body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next?

Ask the client when and how the bruises occurred

The nurse is assessing an older adult in the emergency department. The client has many bruises on the body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next?

Ask the client when and how the bruises occurred

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present?

Bruises, burns, lacerations, missing teeth, and skeletal injuries

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply.

Criticizing Ridiculing Threatening a victim's dog

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes?

Cyberstalking

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse?

Diagnosed with mild dementia

A 19-year-old college student has been date raped. She is in the emergency department undergoing a forensic examination and being assessed by the psychiatric emergency response team. The nurse notices that the client describes the series of events leading up to the rape with a blank facial expression, saying, "I feel like it didn't happen at all." Which of the following statements most accurately describes the client's response?

Dissociation as a defense mechanism to cope with the attack

A client discloses to a nurse therapist that the client has been verbally abusive to the client's 6-year-old child and belittles the child routinely. Which form of abuse best describes the client's treatment of the child?

Emotional abuse

A nurse is preparing a presentation for a senior center about elder abuse. When describing individuals associated with abusing older adults, which group would the nurse most likely identify? Select all that apply.

Family member Adults Children Spouses

Which of the following are biologic indicators of posttraumatic stress disorder (PTSD)?

Flashbacks

Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why?

Giving back the survivor as much control as possible is important.

In violent families, which environment may be the most dangerous place for victims?

Home

The mental health nurse should discuss an emergency plan for leaving abusive situations will when the woman is able to do which of the following? Select all that apply.

Identifies safe places to go Keep emergency money available Makes a spare car key Compile a list of important phone numbers

A nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff?

Importance of measuring the clients' progress in small steps

Which are forms of psychological abuse? Select all that apply.

Insulting Humiliating isolating a person from family

A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a person would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which approach?

Keeping focused on the client's feelings about the client's life situation

A nurse is assessing a survivor of abuse. Which assessment would be most important for the nurse to complete first?

Lethality assessment

A pregnant woman comes to the clinic for a routine visit. Upon examination the nurse notices bruises on the client's upper arms and neck. The client reports that her husband has been abusive to her. The nurse is concerned because abuse during pregnancy can lead to which condition? Select all that apply.

Low birth weight Low maternal weight gain Infections Anemia Miscarriage

The nurse is involved in a community education program for new parents and plans to include information on child abuse. The nurse will teach the parents that the most common form of child abuse is what?

Neglect

Which are common behavioral and emotional responses to abuse? Select all that apply.

One third of abusive men are likely to have come from violent homes. Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. Dependency on the abuser is a common trait found in victims of domestic violence. It is critical for the nurse to demonstrate acceptance after hearing about the abuse so that the victim may begin to gain self-acceptance.

A client has just presented at the emergency department after being raped. What initial action by the nurse would be most appropriate?

Provide emotional support

Which statement requires additional education regarding the truth about rape?

Rape is a crime of passion.

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client?

Rape-trauma syndrome

When health care professionals detect signs of elder abuse in clients, the law requires them to take which action?

Report the abuse to the state authorities.

During the nurse's assessment of a new client on a medical unit, the client confides in the nurse that the client's spouse often "slaps me around" after the client has been drinking. What action should the nurse take in response to this statement?

Report the client's statement promptly to the appropriate authorities.

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what?

Same frequency as in heterosexual couples

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect?

Stalking

Which are common reasons why abused women remain with the abusive partner? Select all that apply.

The abused person is personally and financially dependent on the abuser. The abused person has low self-esteem and defines her success as a person by the ability to make the relationship work. The abused person believes that she is unable to function without her husband. The abused person is afraid that the abuser will kill her if she tries to leave.

Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year-old child?

The child tells sexually explicit stories to peers.

The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply.

The client has few friends. There is a large amount of alcohol use in the home. The client reports that the client's father was abusive during childhood.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply.

The client is embarrassed of the assault. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim.

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply.

The client is physically dependent on the client's son since losing mobility. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic."

A young female immigrant presents in the rural health clinic with facial bruising and a fractured nose. The client is reluctant to give details of the nature of her injuries. Which should be a consideration in providing care for this client?

The client may fear deportation if she seeks public assistance.

The nurse is working in the emergency department with a client who was raped 1 hour ago. Which is most important for the nurse to remember when planning care?

The client may feel threatened by some of the procedures.

A nurse is screening a new client for intimate partner violence (IPV). What aspect of this woman's current circumstances is the most significant risk factor?

The client's family lives on less than $1,000 per month.

The nurse is interviewing the parents of an injured child in the emergency department. Which sign would alert the nurse as the strongest indicator that child abuse may be a problem?

The injury is not consistent with the history or the child's age.

The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse?

The injury occurred several days before the parents sought treatment

Which would not increase the likelihood that an older adult will incur physical abuse?

The older adult is independent with activities of daily living.

The nurse provides care to individuals who have been sexually assaulted during their childhood. Which characteristic is most commonly noted by the nurse during an assessment of such clients?

Unusually aggressive

The cycle of violence or abuse is a reason often cited for why women have difficulty leaving abusive relationships. Which of the following is an inaccurate picture of the cycle of abuse that occurs over time?

Violent episodes are less frequent

The nurse is planning a community education session on elder abuse awareness. Which points should the nurse be sure to include? (Select all that apply.)

Withholding money for necessities is a form of abuse Not helping you get medical attention you need is a form of abuse It is abuse if you feel forced to have sex It is abuse if your caregiver holds your arm too tight

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement?

abandonment

A middle-aged client with young children has been the victim of intimate partner violence (IPV). When providing initial care to this family, the nurse should:

carefully assess the children for signs of trauma.

The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment?

child crying and appearing sad

The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse?

neglect

A client has not been to work in three days. When she returns to work, she is wearing dark glasses. Facial and body bruises are visible. Her supervisor takes her to the occupational nurse. Which assessment is the priority for the nurse?

physical injuries

The nurse is caring for a client who is a victim of intimate violence. The client has pressed charges and the perpetrator is involuntarily remanded to a treatment center for 5 years. The client asks the nurse about the requirements of the treatment center that will help prevent ongoing substance abuse. Which of the following required actions does the nurse include in the correct response?

submit to random drug testing

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.)

the client's father monitors contact with friends has a family history of alcohol abuse must go straight home after school each day

A client who has been victimized repeatedly by a spouse is angry and verbally lashing out on the nurse. Based on the client's behavior, which technique would the nurse use with this client?

use "I feel" statements