Chapter 17 Mental Health Care for Survivors of Violence

9. A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response? A. "To decrease the victimizer's insecurity." B. "To inflict physical harm with the weapon." C. "To terrorize and subdue the victim." D. "To mirror learned family behavior patterns related to weapons."

Answer: C. "To terrorize and subdue the victim." Rationale: The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of POWER and DOMINANCE by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

A group of nursing students is reviewing information about intimate partner violence (IPV). The group demonstrates understanding of this topic when they identify which of the following? A) Men are more likely to be seriously injured even though more women are typically victims. B) Men may not consider behaviors such as slapping or shoving as abuse. C) IPV in same-sex couples occurs less frequently than in heterosexual relationships. D) The reactions to IPV are similar in male and female victims.

B) Men may not consider behaviors such as slapping or shoving as abuse. Feedback: Men are sometimes hesitant to report victimization or may not consider behaviors such as shoving or slapping "abuse." Nearly one in four women and one in nine men are victims of IPV at some point in their lives. Women are much more likely than men to be seriously injured as a result of IPV and to require medical treatment. IPV in same-sex couples occurs with at least the same frequency as in heterosexual relationships, but individuals with same-sex partners may not be afforded the same support. The reaction to IPV may differ by gender.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? A) "He threw me against the wall and started punching my face." B) "He yells at me for not having dinner waiting for him when he comes home." C) "He calls me stupid and incompetent, asking himself why he ever married me." D) "He tells me that he is sorry and that he will never hit me again."

D) "He tells me that he is sorry and that he will never hit me again." Feedback: During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1, or tension building.

11. Which information should the nurse in an employee assistance program PROVIDE to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it. B. Research lawyers that can aid in divorce proceedings. C. File charges of assault and battery. D. Have ready access to the number of a safe house for battered women.

D. Have ready access to the number of safe house for battered women. Rationale: The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.

2. A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman may be a victim of incest.

D. The woman may be a victim of incest. Rationale: The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

Due to an increase in reported violence at the college, a nurse at the health services clinic has been asked to meet with a freshman class about warning signs of relationship violence. Which warning sign will the nurse emphasize to the group to be cognizant of? Dislikes the person's friends Acts indifferently to the person's life choices Is excessively jealous Views the person as superior

Is excessively jealous Explanation: Excessive jealousy is a notable warning sign of possible relationship violence. Abusers often see themselves as superior to the person being abused. An abuser may be excessively involved in the person's life choices and highly opinionated, not indifferent. Controlling the person's choice of friends is a warning sign of abuse, but simple dislike is not necessarily a warning sign.

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what? a) 70% women and 30% men b) 50% women and 50% men c) 90% women and 10% men d) 70% men and 30% women

a) 70% women and 30% men

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? a) Stalking b) Sexual assault c) Intimate partner violence d) Neglect

a) Stalking

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? a) The injury is not consistent with the history or the child's age. b) The parents are argumentative and demanding with emergency department personnel. c) The mother and father tell similar stories regarding what happened. d) The family is poor.

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

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply. a) Threatening a victim's dog b) Ridiculing c) Using assertive language d) Asking for time alone when frustrated e) Criticizing

a) Threatening a victim's dog b) Ridiculing e) Criticizing

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? a) use "I feel" statements b) provide stories about survivors of abuse c) instruct in relaxation techniques d) suggest reenacting the abuse

a) use "I feel" statements

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? a) "I am not sure how I am going to pay for all the things my child will need." b) "I was raised with very strict discipline." c) "My child will love me, unlike my parents ever did." d) "I am going to rely on my sisters for a lot of help raising my baby."

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

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? a) emotional distress b) coping mechanisms c) psychological trauma d) physical injuries

d) physical injuries

A client present to the emergency department (ED) with a rib fracture and states, "I am so clumsy! My spouse always tells me that I need to be more careful." The client's spouse is asked to leave the exam room for the assessment. When the spouse is gone the client states, "My spouse doesn't mean to hurt me. I usually push too hard, and they just loses control!" Which response by the nurse is appropriate? Select all that apply. "It is not your fault." "I am glad that you told me." "I am required to report this abuse." "I am really sorry this happened to you." "You should really leave your spouse."

"It is not your fault." "I am glad that you told me." "I am really sorry this happened to you." When survivors are disclosing abuse, they need privacy and time to tell their story. The nurse should listen attentively without offering unsolicited advice or making judgmental remarks about the possible abuse or the perpetrator. Use validating messages to convey that the survivor is believed and that the nurse is concerned for their safety and well-being. Examples of such messages include "It is not your fault." and "I am glad you told me." and "I am really sorry this happened to you." Although the nurse may be required to report the incident, this response is not therapeutic. Additionally, adult clients must be allowed an appropriate degree of autonomy in deciding how to manage the problem, even if the choice is to remain in the abusive situation. Telling the client that they should leave their spouse is judgmental and will likely affect the therapeutic nurse-client relationship.

While performing a physical examination on an older client, the nurse notes bruising that is in various stages of healing. The nurse suspects the client is being abused based on which client statement? "I take warfarin to treat my atrial fibrillation." "My son drinks a lot of beer every evening after work." "My physical therapist told me to get rid of the throw rugs." "I wish I had used the assistive handles in the bathtub to avoid all of this."

"My son drinks a lot of beer every evening after work." Risk factors for those who are more likely to abuse older adults include using drugs or alcohol, high levels of stress, lack of social support, emotional or financial dependence on the older adult, lack of training in taking care of older adults, and depression. Based on this information, the client statement "My son drinks a lot of beer every evening after work." supports the nurse's suspicion of elder abuse. Warfarin is an anticoagulant that can increase the risk for bruising and bleeding; therefore, this could account for the bruising noted by the nurse. The statement regarding throw rugs and assistive handles are safety measures to decrease the risk for injury; therefore, they are not indicative of an abusive situation.

A nurse is talking to a female client who is a survivor of intimate partner violence. The woman relates that her husband has been told that he has the characteristics of an antisocial personality disorder. The woman also informs the nurse that her husband has an extensive criminal record. The nurse interprets this information and suspects that the woman's husband would most likely demonstrate which behavior? A) A risk for aggressive and assaultive violence toward people within and outside of his family B) Intermittent remorse for the violence and abuse that he commits C) Symptoms of depression along with harboring feelings of inadequacy D) Purposefully remaining socially isolated from people other than those in his family

A) A risk for aggressive and assaultive violence toward people within and outside of his family Feedback: Evidence suggests that when people with borderline personality disorder are distressed, they are predisposed to interpret social situations as threatening and to respond with emotional dysregulation, verbal attacks, and physical violence. People who meet the diagnostic criteria of antisocial personality disorder, have an extensive history of criminal behavior, and who are generally violent are also more likely to be both aggressive and assaultive. These perpetrators have a heightened sensitivity to emotional displays that predispose them to interpret social situations as threatening and to respond with emotional dysregulation, verbal attacks, and physical violence.

A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment? A) Danger Assessment Screen B) Abuse Assessment Screen C) Burgess-Partner Abuse Scale D) Beck Depression Inventory

A) Danger Assessment Screen Feedback: The Danger Assessment Screen, developed by Jacquelyn Campbell and colleagues, is a useful tool for assessing the risk that either an adult survivor or perpetrator will commit homicide. It would be appropriate to use when conducting a lethality assessment. The Abuse Assessment Screen and Burgess-Partner Abuse Scale are appropriate tools to use to screen for violence and abuse. The Beck Depression Inventory is used to screen for depression.

A nurse is caring for a young adult in the mental health clinic. The client tells the nurse that he was physically neglected as a child. The nurse should assess the client for symptoms of which of the following? A) Major depression B) Schizophrenia C) Narcissistic personality disorder D) Panic disorder

A) Major depression Feedback: An important outcome of nursing intervention with survivors is appropriate treatment of any disorder resulting from abuse, such as acute stress disorder, posttraumatic stress disorder, anxiety disorders, dissociative identity disorder, major depression, or substance abuse..

1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child may have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.

A. The child shrinks at the approach of adults. Rationale: The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse? he nurse must discuss the findings with the parents and give them the opportunity to explain. The nurse should talk with another co-worker to be sure the nurse is correct about the assessment. Accurately and thoroughly document the findings and report to the appropriate authorities. Talk to the child and find out if they are experiencing sexual abuse or inappropriate touching.

Accurately and thoroughly document the findings and report to the appropriate authorities The nurse does not have to decide with certainty that abuse has occurred. Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment data. The nurse should never confront the parents of the child since this could be a dangerous outcome for the child. The nurse cannot discuss these findings with others that are not involved in the direct care of the child. The child should not be placed in a position of defense and the nurse should leave questioning of the child to the proper authorities

8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. "I know that it was not my fault." B. "My boyfriend has trouble controlling his sexual urges." C. "If I don't put myself in a dating situation, I won't be at risk." D. "Next time I will think twice about wearing a sexy dress."

Answer: "I know that it was not my fault." Rationale: The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response? A. "Leopards don't change their spots, and neither will he." B. "There are things you can do to prevent him from losing control." C. "Let's talk about your options so that you don't have to go home." D. "Why don't we call the police so that they can confront your husband with his behavior?"

Answer: "Let's talk about your options so that you don't have to go home." Rationale: The most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the "rescuer." Imposing judgments and giving advice is nontherapeutic.

6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate response? A. "These clients don't know life any other way, and change is not an option until they have improved insight." B. "These clients have limited cognitive skills and few vocational abilities to be able to make it on their own." C. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

Answer: "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness." Rationale: The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.

3. A nursing instructor is developing a lesson plan to teach about domestic violence. Which information should be included? A. Power and control are central to the dynamic of domestic violence. B. Poor communication and social isolation are central to the dynamic of domestic violence. C. Erratic relationships and vulnerability are central to the dynamic of domestic violence. D. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

Answer: A) power and control are central to the dynamic of domestic violence Rationale: The nursing instructor should include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

13. Which assessment data should a school nurse recognize as a sign of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

Answer: A. The child is often absent from school and seems apathetic and tired. Rationale: The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

14. A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She states to a nurse, "My father has recently moved back to town." What should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood physical abuse

Answer: B) Possible history of childhood incest Rationale: The nurse should suspect that this client may have a history of childhood incest. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the rape, because this may lead to further emotional trauma. B. Remain nonjudgmental while actively listening to the client's description of the violent rape event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Probe for a further, detailed description of the rape event.

Answer: B) Remain nonjudgmental while actively listening to the client's description Rationale: The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

10. When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

Answer: C Rationale: The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

12. A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

Answer: C Expressed response pattern Rationale: The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

5. A raped client answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this client's responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

Answer: The client may be demonstrating a controlled response pattern. Rationale: This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.

A nurse is caring for a child who had experienced sexual abuse. Which are expected behaviors of a child who has experienced sexual abuse? Select all that apply. Avoidance of sexually related content Secretiveness of behaviors Open and honest discussion about history High self-esteem Distorted view of sex

Avoidance of sexually related content Secretiveness of behaviors Distorted view of sex A victim of prolonged sexual abuse will develop low self-esteem, a feeling of worthlessness, and a distorted view of sex. The child may become withdrawn, distrustful, or suicidal. Other characteristics of children who have been sexually abused include an unusual interest or avoidance of sexually related content, seductiveness, refusal to go to school, delinquency, secretiveness, and unusual aggressiveness.

A nurse is presenting to a church group a program about domestic violence. During the presentation, a member of the audience asks the nurse to explain what "intergenerational transmission of violence" means because he has seen that phrase used in the media. Which of the following responses by the nurse would be most appropriate? A) "People who are violent are that way because of the various neurochemical imbalances in their brains." B) "People who grow up in violent home situations tend to be involved in domestic violence situations as an adult." C) "Recent research has identified a gene that is responsible for transmission of a risk for violent behavior that is passed on from generation to generation." D) "Domestic violence seems to skip every other generation when it is traced in families."

B) "People who grow up in violent home situations tend to be involved in domestic violence situations as an adult." Feedback: Violent families create an atmosphere of tension, fear, intimidation, and tremendous confusion about intimate relationships. Children in violent homes often learn violent behavior as an approved and legitimate way to solve problems, especially within intimate relationships. The social learning or intergenerational transmission of violence theory posits that children who witness violence in their homes often perpetuate violent behavior in their own families as adults. Moreover, children who grow up in violent homes learn to accept violence and expect it in their own adult relationships. Neurochemical imbalances, genetics, or skipping generations are unrelated to this theory.

A school nurse is aware that a student has requested aspirin three times during the past week because his "back hurts." The nurse has noticed that he often wears long-sleeved sweaters and sweatshirts even in warm weather. The nurse suspects that the student may be the victim of physical abuse. The nurse is preparing to ask the child about his ongoing backache. Which of the following would the nurse anticipate being reported by the child if he was being abused? A) His father is beating him on a regular basis B) Be reluctant to report abuse because of shame or fear of retaliation C) Give the same reason his sister would give were she asked to explain his injuries D) Carefully explain that his mother disciplines him because she loves him

B) Be reluctant to report abuse because of shame or fear of retaliation Feedback: Most survivors do not report violence to health care providers without specifically being asked about it. Survivors may be reluctant to report abuse because of shame and fear of retaliation, especially if the victim depends on the abuser as a caregiver. In addition, children may fear they will not be believed.

A nurse is working with a female client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which of the following would be most important for the nurse to do? A) Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence. B) Inform the client that if she leaves the abusive situation, there is a possibility her partner will attempt to murder her. C) Assist the client in finding a new apartment and a new job so she will be safe after she leaves her current situation. D) Suggest that the client legally change her name and move out of state so she will be safe from future harm.

B) Inform the client that if she leaves the abusive situation, there is a possibility her partner will attempt to murder her. Feedback: Survivors must understand the cycle of violence and the danger of homicide that increases as violence escalates or when the survivor attempts to leave the relationship. Although survivors also need information about resources (e.g., shelters for battered women), legal services, government benefits, and support networks, the nurse first needs to discuss the possibility of the perpetrator's reaction and the possibility of extreme violence leading to death.

A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following? A) Violence B) Intimidation C) Jealousy D) Fear

B) Intimidation Feedback: Stalking is a crime of intimidation in which stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Rape is a crime of violence.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which of the following would the nurse address first? A) Devising an escape route B) Recognizing the signs of danger C) Identifying a safe place to hide D) Identifying a signal to indicate it is safe to leave

B) Recognizing the signs of danger Feedback: One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.

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? A) "He always tells me that the abuse never happened." B) "He tells me who I can and cannot see." C) "He tells me that he'll tell Child Services I'm a bad mother." D) "He acts like he's the master of his castle and I'm his servant."

C) "He tells me that he'll tell Child Services I'm a bad mother." Feedback: 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 his castle reflects power and control through the use of the male privilege.

An emergency department nurse is assessing a female client with traumatic injuries. To assess whether the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? A) "Is your partner being mean to you?" B) "Why do you think your husband has beaten you?" C) "It looks like someone has hurt you. Tell me about it." D) "Can you describe the person who did this to you?"

C) "It looks like someone has hurt you. Tell me about it." Feedback: The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize her thoughts and feelings. Asking whether the partner is being mean or asking why the client thinks the husband has beaten her already assumes that the client has been abused. Asking about the person who did this would be ineffective because survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly.

A nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her son, 48 years of age. Which of the following would be most important for the nurse to keep in mind before interviewing the family? A) A top nursing priority would be to legally remove the son from the home. B) The main focus of the nurse's actions should be on improving the elderly mother's self-esteem. C) The nurse must allow the older adult mother to decide whether she wants to leave the situation. D) Placement for the older adult woman in a nursing home within the community is crucial.

C) The nurse must allow the older adult mother to decide whether she wants to leave the situation. Feedback: Removing children and older adults from their families or caregivers often is necessary to ensure immediate safety. If the home of an abused or neglected child or older adult cannot be made safe, the nurse must facilitate the involvement of other professionals in placing the child or older adult in a foster home or nursing home. Still, intervening in cases of elder abuse is not a clear-cut issue. When an older adult's decision making is not impaired (competence is the legal term), he or she must be allowed an appropriate degree of autonomy in deciding how to manage the problem, even if the choice is to remain in the abusive situation. Forcing someone to do something against his or her wishes is in itself a form of victimization and denies autonomous decision making.

A female client has been admitted to an inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority? A) Nutritional status B) Hydration status C) Sleep patterns D) Suicide risk

D) Suicide risk Feedback: The first, and most important, assessment conducted is a lethality assessment that determines whether the survivor's life is in danger, either from homicide or suicide, and, if children are in the home, whether they are in danger. Then the physiologic areas such as nutrition, hydration, and sleep can be assessed.

A nurse is conducting a public information seminar on the topic of rape and sexual assault at a local community center. Which of the following would the nurse include when describing power rapists? A) Committed by sadistic perpetrators who plan the rape before committing it to experience erotic enjoyment in response to the victim's suffering B) Target very young or elderly victims, may involve extreme force, and often results in victim injury C) Are not planned ahead of time and result from the perpetrator being obsessed with uncontrollable sexual urges D) Target victims near the age of the perpetrators and involve minimal physical force and intimidation in controlling their victims

D) Target victims near the age of the perpetrators and involve minimal physical force and intimidation in controlling their victims Feedback: Power rapists commit 55% of sexual assaults. They often attack people their own age and use intimidation and minimal physical force to control their victims. Their assaults are generally premeditated. Anger rapists commit 40% of sexual assaults. These rapists tend to target either very young or older adult victims. They may use extreme force and restraint that results in physical injury to the victim. Sadistic rapists commit 5% of sexual assaults; however, they are the most dangerous. Their crimes are premeditated, and they often torture and kill their victims. Sadistic rapists derive erotic gratification from their victims' suffering.

During an interview, a young school-age child tells a nurse that they are often left alone at home by the child's parents. Which action is appropriate by the nurse to take? Continue with the interview and do not acknowledge the statement. Report the child's information to the child protection agency. Tell the parents that it is not acceptable to leave a young school-age child at home alone. Discuss the accusations with a co-worker to see if they think it is true.

Report the child's information to the child protection agency. Being left alone at such a young age is an indication of neglect and not having needs met by the parental figures. If neglect is suspected by the nurse, it must be immediately reported to child protective services. The nurse should not ignore the situation since it could endanger the child if not reported. It is not the nurse's responsibility to discuss this with the parents since it may give them a warning to cover up the neglect and further endanger the child. It is inappropriate to discuss the care of the child with someone not involved in the care of the child.

The nurse provides care to a client at a scheduled health maintenance visit who states, "My partner abuses me. I don't know what to do to ensure my safety." Which is the best response by the nurse based on the client's statement? a) "Tell me more about your situation so that I can help you." b) "Do you know why your partner abuses you?" c) "Is there anything that you could have done to avoid the abuse?" d) "I will need to report this to your practitioner."

a) "Tell me more about your situation so that I can help you." Establishing a trusting nurse-client relationship is one of the most important steps in caring for any person experiencing violence. When interviewing, to establish rapport and put the survivor at ease, start with the least sensitive areas and progress to more sensitive topics. Survivors are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality and providing a quiet, private place in which to interact. A supportive, empathetic approach is most effective. Based on this information, the best response by the nurse is to say, "Tell me more about your situation so that I can help you." Asking why the partner abuses the client is judgmental and, therefore, not therapeutic. Although mandatory reporting may be required, this is not the best response by the nurse based on the initial client statement. Asking the client what can be done to avoid the abuse indicates judgment and is, therefore, not therapeutic.

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? a) "You have the right to be safe and respected." b) "I wonder if your perceptions of the relationship are accurate." c) "Relationship counseling can be very helpful." d) "I am here to help you through every step of this process."

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

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) A baby with contrecoup injuries to the brain b) A 3-year-old with a deep finger laceration c) A 6-year-old is being seen for the 5th time for a urinary tract infection d) A 3-month-old with a fractured femur e) A 15-month-old with shortness of breath after peanut ingestion

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

Which assessment finding can help the nurse differentiate a child experiencing child neglect rather than child abuse? a) A young child is admitted to the hospital with hypothermia because the child is inadequately dressed. b) A child tells a social worker that the child does not like it when the child's mother's boyfriend touches the child "down there." c) A child is brought to a clinic by a parent who is unable to adequately explain how the child broke an arm. d) A child exhibits multiple scars on the back and buttocks upon examination.

a) A young child is admitted to the hospital with hypothermia because the child is inadequately dressed.

Which type of elder abuse involves leaving an older adult and no longer providing care for the individual? a) Abandonment b) Physical c) Neglect d) Emotional

a) Abandonment

Which characteristics are found in violent families? Select all that apply. a) Abuse of power and control b) Social isolation c) Adequate support systems d) Alcohol use disorder

a) Abuse of power and control b) Social isolation d) Alcohol use disorder

The nurse is caring for a 16-year-old boy with a history of being sexually abused. The nurse might expect this adolescent to ... a) Experience nightmares and flashbacks b) Have no ill effects due to his age c) Reject his mother for not protecting him d) Want to confront the perpetrator

a) Experience nightmares and flashbacks

The mental health nurse should discuss an emergency plan for leaving an abusive situation when the client is able to do which of the following? Select all that apply. a) Keep emergency money available b) Compile a list of important phone numbers c) Compose a note to explain departure d) Identify safe places to go e) Have access to a car key or other transportation

a) Keep emergency money available b) Compile a list of important phone numbers d) Identify safe places to go e) Have access to a car key or other transportation

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client? a) Rape-trauma syndrome b) Hopelessness c) Anxiety d) Fear

a) Rape-trauma syndrome

Which are common reasons why abused women remain with the abusive partner? Select all that apply. a) The abused person believes that she is unable to function without her husband. b) The abused person is afraid that the abuser will kill her if she tries to leave. c) The abused person is personally and financially dependent on the abuser. d) The abused person has low self-esteem and defines her success as a person by the ability to make the relationship work. e) The abused person uses alcohol or illegal drugs in the home.

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

A coherent older client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which is the most likely reason that the client has not reported the abuse? a) The client is emotionally close to the children and does not want to bring them harm. b) The client has no financial resources to hire legal representation against the client's children. c) Laws do not provide protection against abuse when the suspect(s) is/are family members. d) The client cannot claim abuse if there is no evidence of physical harm.

a) The client is emotionally close to the children and does not want to bring them harm.

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. a) The client reports that the client's father was abusive during childhood. b) The client has few friends. c) The client is in charge of the family finances. d) The client holds a dominant role in the family. e) There is a large amount of alcohol use in the home.

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

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. a) They have a fear of being blamed for the incident. b) The perpetrator may use coercion or threats to control the victim. c) The person is concerned about the financial issues associated with the hospitalization. d) The victim is responsible for the attack. e) The client is embarrassed of the assault.

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

A nurse is giving a talk about child abuse to a local community group. When discussing risk factors for child abusers, which would the nurse identify as the most likely profile of the perpetrator of fatal child abuse? a) Unemployed young woman who dropped out of high school b) Middle-aged woman with a college degree c) Middle-aged, wealthy businessman d) Young college graduate who recently gave birth to her first child

a) Unemployed young woman who dropped out of high school

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? a) Unusually aggressive b) Overly self-confident c) Overly social d) Too trustful

a) 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? a) Violent episodes are less frequent b) Violent episodes are more frequent c) Severity of the injuries worsen d) The period of remorse disappears

a) Violent episodes are less frequent

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: a) carefully assess the children for signs of trauma. b) reassure the client that this will never happen again. c) determine what initially caused the violence to begin. d) teach the client life skills for moving on from the relationship.

a) carefully assess the children for signs of trauma. Children are inevitable victims in an IPV situation and must be assessed and cared for accordingly. The nurse must avoid false reassurance. It is unnecessary, and often impossible, to identify specific causes for IPV. Relationship skills can be addressed in follow-up care.

A client runs to the urgent care center because the spouse is at home drinking and waving a gun around while yelling at the children. Which action should the nurse take first? a) contact the police b) assess the client for injuries c) call for an ambulance for transport to the hospital d) call a family member to pick up the children

a) contact the police The client was in a lethal situation and escaped for help. Since children are in the home with an adult who is impaired with a firearm, the police should be immediately notified. There is no evidence to suggest the client is injured. The client should not return to a potentially lethal situation however the children need to be removed. The police should remove the children and not another family member since this could place them all in harm's way.

The nurse is assessing a client and suspects that the client is a victim of intimate partner violence. The client is experiencing palpatations. What additional findings should the nurse assess the client for related to intimate partner violence? Select all that apply. a) missing teeth b) wearing clothing inappropriate for the weather c) low blood pressure d) variety of wounds in different stages of healing e) inability to fully extend the right leg

a) missing teeth b) wearing clothing inappropriate for the weather d) variety of wounds in different stages of healing e) inability to fully extend the right leg

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.) a) must go straight home after school each day b) feeling left out of peer group c) the client's father monitors contact with friends d) has a family history of alcohol abuse e) feeling social pressure to use alcohol

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

The nurse is approached by a teacher who suspects a student is being neglected after observing changes in the student's behavior. The teacher asks the nurse what other behaviors to watch for. Which symptoms of neglect should the nurse include in the discussion? Select all that apply. a) refusing to answer when called on in class b) smoking a cigarette after school c) fighting with other students d) deteriorating grades in school e) not having money for extracurricular activity fees

a) refusing to answer when called on in class b) smoking a cigarette after school c) fighting with other students d) deteriorating grades in school

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence? a) "His father physically abused his mother for years." b) "I don't know what else I can do to keep him from getting angry at me." c) "He doesn't like it when I go out with my girlfriends." d) "He was so much nicer when we started dating."

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

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? a) Call the nursing supervisor immediately b) Ask the client when and how the bruises occurred c) Notify the physician that abuse is suspected d) Follow the facility's policy and procedures for reporting abuse

b) Ask the client when and how the bruises occurred

Which of the following are biologic indicators of posttraumatic stress disorder (PTSD)? a) A feeling of unreality about oneself b) Flashbacks c) Memory difficulties d) Auditory hallucinations

b) Flashbacks

A young client telephones the emergency department and loudly tells the nurse, "I've been raped! Please help me!" Which is the priority for the nurse to determine? a) If the client had bathed, douched, or changed clothes b) If the client was in a safe place, the client's condition, and if transportation is available c) If the client knew the assailant, knew the client's location, and had notified the police d) If the client has insurance, if the client could get to the hospital by herself, and if pregnancy is a possibility

b) If the client was in a safe place, the client's condition, and if transportation is available

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? a) Identification of consequences from changes made by survivors as minimal b) Importance of measuring the clients' progress in small steps c) Expectation that survivors will accept change right away d) Encouragement for staff discussion about specific clients to gain support

b) Importance of measuring the clients' progress in small steps

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? a) Physical abuse b) Neglect c) Emotional abuse d) Sexual abuse

b) Neglect

In a toddler, which injury is most likely the result of child abuse? a) A hematoma on the occipital region of the head b) Several small, circular burns on the child's back c) A 1-inch forehead laceration d) A small, isolated bruise on the right lower extremity

b) Several small, circular burns on the child's back

Which is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency? a) Physical abuse b) Stalking c) Incest d) Rape

b) Stalking Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Stalking is a crime of intimidation. Rape is the penetration of any bodily orifice by the penis, fingers, or an object. Incest involves sexual contact between family members. Physical abuse involves bodily harm.

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. a) The client self-describes and describes the client's child as "not well-off, but not terribly poor either." b) The client is physically dependent on the client's son since losing mobility. c) The client has no income or savings of the client's own. d) The client and client's child are recent immigrants to the United States. e) The client's son describes the client as "needy, helpless, and pathetic."

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

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? a) There are bruises over the child's bony prominences b) The injury occurred several days before the parents sought treatment c) Both parents report the exact same details pertaining to the injurious event d) The parents appear overprotective of the child

b) The injury occurred several days before the parents sought treatment

Which would not increase the likelihood that an older adult will incur physical abuse? a) An older adult reports frequent multiple bruises that are related to falls. b) The older adult is independent with activities of daily living. c) The older adult lives with a son who receives financial aid. d) The older adult has difficulty with mobility and can become confused.

b) The older adult is independent with activities of daily living.

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? a) physical b) abandonment c) emotional d) neglect

b) abandonment

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? a) physical b) neglect c) sexual d) psychological

b) neglect

A client states to the nurse, "My husband hits me. I want to leave him, but I have to be sure that I can leave and won't have to go back." Which question does the nurse ask during the psychosocial interview to assess the client's SOCIAL network? a) "Does your husband criticize and belittle you?" b) "Does your husband blame you for his abusive behavior?" c) "Do you have any friends who can provide emotional support?" d) "Did you experience any form of abuse when you were a child?"

c) "Do you have any friends who can provide emotional support?" An evaluation of social networks provides additional clues of psychological abuse and controlling behavior. Having supportive family or friends is crucial in short-term planning for developing a safety plan and is also important to long-term recovery. A survivor cannot leave an abusive situation with nowhere to go. Supportive family and friends may be willing to provide shelter and safety, as well as emotional support. Asking if the spouse criticizes and belittles the client assesses self-esteem, and inquiring about blame assesses for guilt and shame. Asking the client if they experienced any form of abuse as a child assesses for revictimization.

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) A client who is currently exploring long-term care options for her elderly father b) A client who expressed interest in joining a grief support group following the death of her husband c) A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic d) A client who has brought her young son to the emergency department because he fell at the playground and may have an arm fracture

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

A client has just presented at the emergency department after being raped. What initial action by the nurse would be most appropriate? a) Perform a nursing history and physical as quickly as possible b) Encourage the client to file charges immediately c) Provide emotional support d) Refer the client to a rape crisis hotline

c) Provide emotional support In the emergency setting, the nurse is an essential part of the team in providing emotional support to the victim. All of the nurse's actions must proceed from a position of emotional support and validation. The client's trauma would be made worse if the nurse proceeded with assessments or spoke about legal actions before establishing rapport and support. The client is in the emergency department so there is no need to refer to a hotline.

The community health nurse meets with the family members of an older adult client. The nurse includes which in the plan of care as a preventive measure to guard against elder abuse? a) Assist in the transfer of legal authority for care to the primary caregiver b) Reassure the primary caregiver that he or she is in the best position to provide care to the client c) Provide the primary caregiver with additional resources to meet the client's needs d) Teach the primary caregiver skills to meet all of the client's needs

c) Provide the primary caregiver with additional resources to meet the client's needs

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? a) The client immigrated less than 5 years ago. b) The client has no extended family in the area. c) The client's family lives on less than $1,000 per month. d) The client has four children.

c) The client's family lives on less than $1,000 per month. Low income is a salient risk factor for IPV. Recent immigration, larger than average numbers of children, and a lack of extended family are not noted as major risk factors.

A female college student comes to the counseling center and tells the nurse she is afraid of her boyfriend. She states, "He is so jealous and overprotective; he wants to know where I am and who I'm with every minute." The nurse recognizes this as which of the following? a) A situation requiring a restraining order b) An overreaction on the part of the student c) The tension-building phase of the violence cycle d) The boyfriend is insecure and needs reassurance

c) The tension-building phase of the violence cycle

Which referral would a nurse make for a client who was badly beaten by a spouse, has no place to go, and no financial means? a) law enforcement b) community food bank c) a women's shelter d) vocational counseling

c) a women's shelter

The nurse provides care to a 4-month-old infant who presents to the emergency department (ED) with the parents at the advice of the pediatrician due to poor feeding and potential dehydration. Which finding noted by the nurse during the physical examination indicates the need to assess for child abuse? a) dry mucous membranes b) mild diaper rash c) ecchymosis to the arms d) sunken fontanelle

c) ecchymosis to the arms

The nurse provides care for a client who reports intimate partner violence (IPV). Which intervention does the nurse include in the client's plan of care to address safety planning? a) providing the client with supplies to treat physical injuries b) teaching about sleep hygiene techniques c) educating about perpetrator about behaviors indicative of losing control d) initiating the paperwork required for a guardianship

c) educating about perpetrator about behaviors indicative of losing control

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? a) "Working with survivors of sexual trauma is very fulfilling work." b) "Survivors of sexual assault deserve the best care I can give them." c) "I've put the incident behind me and seldom think of it." d) "I've been supported by health care professionals and now I want to support other survivors."

d) "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? a) "Let's talk about what happened to you again. It can help." b) "Life is different for you now, you will gradually accept that." c) "You are a victim. You need to give yourself some time." d) "It can take at least a year or more to get back to where you were before."

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

The nurse provides care to a client who presents for an initial prenatal appointment. When reviewing the client's medical record, intimate partner violence (IPV) is documented. Which client statement made during the health history interview indicates phase 1 of the cycle of violence? a) "My husband has not hit me since he promised to stop drinking several months ago." b) "My husband is happy about this pregnancy and even bought me flowers." c) "My husband begged me not to leave him after the last incident." d) "My husband monitors my cell phone calls every month when the bill arrives."

d) "My husband monitors my cell phone calls every month when the bill arrives."

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? a) Harassment b) Jealousy c) Isolation d) Cyberstalking

d) Cyberstalking

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? a) Reaction formation to manage the anger she feels toward her attacker b) Denial as a defense mechanism to cope with the pain of the attack c) Shock phase of a crisis, with repressed feelings associated with the attack d) Dissociation as a defense mechanism to cope with the attack

d) Dissociation as a defense mechanism to cope with the attack

When attempting to preserve evidence from a possible rape with no report of oral sex, the female victim should be instructed that which self-care activities are permitted? a) Douching b) Showering c) Changing clothes d) Drinking a glass of water

d) Drinking a glass of water

Which statement requires additional education regarding the truth about rape? a) Rape can occur between married individuals. b) No person deserves to be raped. c) No person wants to be raped. d) Rape is a crime of passion.

d) Rape is a crime of passion.

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what? a) Half as frequent as in heterosexual couples b) Twice as often as in heterosexual couples c) Three times more frequent as in heterosexual couples d) Same frequency as in heterosexual couples

d) Same frequency as in heterosexual couples

Which assessment finding should cause the nurse the greatest concern regarding the possible abuse of an older adult client? a) Has lost weight since breaking an ankle b) Often cries, mourning the recent death of a beloved pet c) Has developed a urinary tract infection d) Sends money every month to each adult child

d) Sends money every month to each adult child

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? a) The nurse will need to make decisions for this client. b) Evidence collection according to procedures is not as important as treating the client's injuries. c) The client should set aside any angry feelings until physical care is completed. d) The client may feel threatened by some of the procedures.

d) The client may feel threatened by some of the procedures. Many of the examination procedures, such as a pelvic exam, may cause the client to feel violated again. The client needs emotional support and evidence collection as well as physical care. The client will require emotional support but this does not mean that the nurse should adopt a role as a surrogate decision-maker. It is simplistic and condescending to expect a client to "set aside" feelings immediately following a severe trauma. Medical treatment and evidence collection are both vitally important. Emotional support is a nursing priority in the immediate care of a client following sexual assault.

The nurse provides care for a client who presents to the emergency department (ED) with injuries sustained due to intimate partner violence (IPV). Which question does the nurse include to determine the client's risk for danger when conducting the interview portion of the assessment process? a) "Have you ever tried to leave your partner after an episode of physical violence?" b) "Is there a possibility that you are pregnant and that is what caused the incident?" c) "When did the physical violence with your partner begin?" d) "Have you ever tried to leave your partner after an episode of physical violence?"

"Have you ever tried to leave your partner after an episode of physical violence?"

Which question does the nurse include when assessing a client for physical violence associated with intimate partner abuse (IPV)? a) "Does your partner ever strike or kick you?" b) "Does your partner criticize or insult you?" c) "Does your partner humiliate you in public settings?" d) "Does your partner destroy your property?"

a) "Does your partner ever strike or kick you?" Physical abuse involves any act of aggression with or without use of an object or weapon that results in injury, pain, or impairment to another. Examples include striking, kicking, shoving, choking, burning. Based on this information, the question the nurse asks when assessing for physical violence associated with IPV is "Does your partner ever strike or kick you?" Criticism, insults, destroying personal property, and humiliation in public settings are examples of psychologic, not physical, violence associated with IPV.

The nurse can assess potential victims of domestic violence by asking which question? a) "Has a past or current partner ever caused you to be afraid?" b) "What did you do right before your partner hit you?" c) "Do you need the number of a shelter?" d) "What is your history of physical injuries?"

a) "Has a past or current partner ever caused you to be afraid?"

The nurse provides care to a client who is experiencing intimate partner violence (IPV). The client lives in a rural area and asks the nurse how they can receive support. Which response by the nurse is appropriate? a) "I can provide you with a list of virtual support groups." b) "You should discuss this issue with your practitioner." c) "I think it is best if you just make a plan to leave and stick to it." d) "You should find a support group that that meets during your lunch hour."

a) "I can provide you with a list of virtual support groups."

The nursing student learning about child abuse correctly identifies which of the following individuals to be at the highest risk for abuse? a) 5-year-old girl b) 16-year-old girl c) 18-year-old boy d) 12-year-old boy

a) 5-year-old girl