Chapter 9: Violence and Abuse
The nurse who counsels clients who suffer from intimate partner violence (IPV) understands that IPV can come in which form(s) of abuse? Select all that apply. - emotional abuse - physical abuse - financial abuse - sexual abuse - spiritual abuse
Answer: - emotional abuse - physical abuse - financial abuse - sexual abuse
Which type of elder mistreatment involves harm of self-worth? A.) emotional B.) physical C.) neglect D.) abandonment
Answer: A.) emotional
Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)? A.) flashbacks B.) memory difficulties C.) auditory hallucinations D.) a feeling of unreality about oneself
Answer: A.) flashbacks
A 16-year-old pregnant client presents to the office for the third time this week. While completing the client's admission, the nurse screens for intimate partner violence. The client responds, "I have already told you twice this week I am not being abused. Why do you keep asking me these questions?" Which response by the nurse is best? A.) "Based on your age and being pregnant, you are at high risk." B.) "It is protocol to screen all clients for intimate partner violence at every visit." C.) "It is possible for you to be a victim since your last visit and I want to ensure your safety." D.) "You have been here three times this week and I am concerned about you."
Answer: B.) "It is protocol to screen all clients for intimate partner violence at every visit."
A client at 36 weeks' gestation presents in the emergency department with a broken arm. The client states, "I fell while cooking dinner." During the assessment, the nurse notes no prenatal care for this pregnancy, as well as bruises in multiple stages of healing on the client's abdomen, arms, and chest. What action will the nurse perform next? A.) Notify the health care provider of the findings B.) Ask the client how she acquired the bruises C.) Document the findings in the client's chart D.) Provide brochures on shelters for victims of intimate partner violence
Answer: B.) Ask the client how she acquired the bruises
The nurse is planning to provide education to a female client who is a victim of sexual assault. Which statement is a priority for the nurse to include in the education? A.) "Sexual violence can happen to anyone at any time." B.) "Someone will call you with the results of your laboratory tests." C.) "You have the option of taking an emergency contraceptive pill." D.) "A counselor can help you process what you have been through."
Answer: C.) "You have the option of taking an emergency contraceptive pill."
During a prenatal examination the nurse observes bruises on the client's arms and a black eye. When asked about the bruises, the client states, "It was an accident. My spouse just had a bad day at work, and I was late getting dinner prepared. But my spouse is being so kind now; my spouse brought me flowers yesterday. My spouse is looking for a new job, so it will not happen again." This client is in which phase of the cycle of violence? A.) The resolution and reorganization phase B.) The tension-building phase C.) The honeymoon phase D.) The acute explosion or incident phase
Answer: C.) The honeymoon phase Rationale: Being kind, showing love, and bringing gifts after an episode of abuse is characteristic of the honeymoon stage of the cycle of violence. The tension-building phase is when the tension begins to increase due to activities such as being late or the abuser having a bad day or being intoxicated. The acute explosion phase is the violent act as anger or tension is released. The resolution and reorganization phase occurs when the abused partner leaves the situation.
The nurse presents information on intimate partner violence (IPV) to a group of community members. The nurse will provide additional teaching when a community member makes which statement? A.) "I am lucky my spouse loves me. Genuine love will prevent me from being a victim." B.) "Drugs and alcohol can really make an IPV situation much worse." C.) "It is not just men abusing women; women can be abusive, too." D.) "I have heard getting pregnant can make an IPV situation even worse."
Answer; A.) "I am lucky my spouse loves me. Genuine love will prevent me from being a victim."
A nurse has experienced success by utilizing the SAVE model to evaluate clients for possible intimate partner violence. Which action would be least appropriate for the nurse to address? A.) validating that the client is the cause B.) asking for evidence of the abuse C.) screening all clients for violence D.) educating the client concerning the community resources available
Answer; A.) validating that the client is the cause
The nursing instructor is teaching about violence and informs the students about which of its distinct phases? Select all that apply. - tension-building phase - prehoneymoon phase - acute battering phase - honeymoon phase - courting phase
Answer: - tension-building phase - acute battering phase - honeymoon phase
The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases? A.) honeymoon phase B.) tension-building phase C.) battering incident D.) hopeless stage
Answer: D.) hopeless stage
A 16-year-old girl presents to the emergency department following a rape. Which action will the nurse complete first? A.) Provide the client privacy and assess for injuries. B.) Counsel the client to help increase self-esteem. C.) Arrange for a follow-up visit for treatment. D.) Assist the client with showering and hygiene.
Answer: A.) Provide the client privacy and assess for injuries.
The nurse suspects a pregnant client is a victim of intimate partner violence (IPV). When the nurse asks the client if her partner abuses her, the client responds, "Oh no, my partner does not hit me." Which response by the nurse is most appropriate? A.) "There are many types of intimate partner violence beyond physical abuse." B.) "It is important for you to think about the safety of your unborn child." C.) "I am glad to be wrong. I will continue with your assessment." D.) "I will give you information on shelters and resources for victims of IPV just in case."
Answer: A.) "There are many types of intimate partner violence beyond physical abuse."
A nurse is performing a physical examination of a pregnant woman. During examination, the nurse notices a bruise on the client's abdomen. Which action should the nurse take? A.) Ask the client to account for the bruise. B.) Assume that the bruise is from an accident and not worry about it. C.) Make a note in the client's chart regarding the finding, and plan to observe for other signs of intimate partner violence in the future. D.) Assume that the bruise is from intimate partner violence, and call the police while the client is still in the room.
Answer: A.) Ask the client to account for the bruise.
A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client? A.) Being nonjudgmental B.) Giving assurances of help C.) Establishing a plan to protect the client D.) Having the client be honest about the injuries
Answer: A.) Being nonjudgmental
A 19-year-old male client is brought to the emergency department after being raped. Which nursing action is most appropriate at this time? A.) Listen to the client's description of what happened. B.) Help the client determine how to prevent a future rape. C.) Provide information on counseling centers to the client. D.) Assist the client with showering and changing into clean clothing.
Answer: A.) Listen to the client's description of what happened.
When implementing an intervention for a client experiencing intimate partner violence, what is the primary goal? A.) The client will regain a sense of control in life. B.) The client will be removed from the abusive relationship. C.) The client will be able to care for oneself. D.) The client will be able to stand up to the abuser.
Answer: A.) The client will regain a sense of control in life.
While performing an assessment on a female client, the nurse notes signs of sexual assault. When questioned, the client states, "I am married, so I have not been raped or abused." What statement by the nurse is most appropriate? A.) "Can you tell me how long you have been married?" B.) "The lines of assault are very blurred when you are married." C.) "I apologize, I did not realize that you are married." D.) "If you do not consent, it is still assault when you are married."
Answer: D.) "If you do not consent, it is still assault when you are married."
The nurse is assessing a client who was a previous victim of rape. The nurse believes the client is in the integration and recovery phase following the rape. Which action will the nurse recommend to the client for continued recovery? A.) pressing formal charges against the abuser B.) returning to a normal daily routine C.) changing positions with current employer D.) joining a rape survivor group
Answer: D.) joining a rape survivor group
A woman arrives at the neighborhood clinic asking for care related to symptoms that include bruising, lacerations and vague reports of perineal discomfort. The nurse assesses and provides care for the client's physical condition, then questions the client. Which is the best question for the nurse to ask? A.) "Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?" B.) "Your injuries suggest that you are experiencing physical and or sexual abuse. Would you like to talk about what's happening?" C.) "It appears that your injuries are a result of abuse and violence. Do you feel safe at home?" D.) "Physical abuse is not something you have to tolerate. Would you like me to notify the police?"
Answer; A.) "Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?" Rationale: Often, after a woman is victimized, she will report physical ailments, which gives her the opportunity to visit a health care setting. Opening up the possibility for women to express themselves about their experience of abuse to a nurse sends a clear message that violence should never be tolerated and not kept hidden. Presenting the opportunity in a nonthreatening, nonjudgmental manner will encourage the woman to open up to the problem either immediately or in the future.
The nurse is assessing a client whose partner is present. The nurse notes the partner swears and yells, makes lavish promises, and threatens to hit the client. Which nursing intervention is a priority? A.) Ask the partner to leave the room. B.) Notify the facility authorities. C.) Document the findings. D.) Ask the partner to remain calm.
Answer; A.) Ask the partner to leave the room.
A client who is a rape survivor has appeared to cope very well. However, at a routine visit several months later, the client describes a new onset of nightmares and flashbacks. Which action by the nurse is most appropriate for this client? A.) Refer the client to a psychologist for psychotherapy treatment. B.) Recommend the client receive a selective serotonin reuptake inhibitor (SSRI). C.) Determine the client's actions and routine prior to bed each night. D.) Encourage the client to begin writing a journal reflecting on the rape.
Answer: A.) Refer the client to a psychologist for psychotherapy treatment.
The nurse is talking to a client who is a survivor of intimate partner violence. The client states that the spouse has the characteristics of antisocial personality disorder. The client also informs the nurse that the spouse has an extensive criminal record. The nurse interprets this information and suspects that the client's spouse would demonstrate which behavior? A.) moderate to severe violence with people both within and outside the family B.) intermittent remorse for the violence and abuse committed C.) symptoms of depression along with harboring feelings of inadequacy D.) purposefully remain socially isolated from people other than those in the family
Answer: A.) moderate to severe violence with people both within and outside the family
Nurses sometimes have difficulty assessing clients for intimate partner violence. Which screening protocol is most thorough when assessing for violence? A.) the SAVE model B.) the SBAR model C.) the FACE model D.) the RACE model
Answer: A.) the SAVE model Rationale: The SAVE model is a screening protocol that nurses can use when assessing a client for intimate partner violence. It stands for screen, ask, validate and evaluate. The SBAR is a reporting tool used by nurses when handing off clients. The FACE model is a pain scale used to evaluate pain in children. The RACE model is used when there is a fire.
When a pregnant client is victim of intimate partner violence during pregnancy, what complication is likely to occur after birth due to the abuse? A.) edema B.) postpartum depression C.) low birth weight D.) schizophrenia
Answer; B.) postpartum depression
When initiating care for a client suspected of being a victim of human trafficking, what is the nurse's primary responsibility? A.) Building trust B.) Protecting privacy C.) Supporting autonomy D.) Remaining nonjudgmental
Answer: A.) Building trust
A client is receiving treatment for injuries sustained during a fight with a partner. The nurse observes the partner visit the client daily in the hospital and appears very solicitous and contrite. The client states, "My partner always apologizes and brings gifts after a fight." Which response by the nurse is appropriate? A.) "Sometimes abusive partners try to apologize but this does not mean the person wants to change." B.) "Your partner seems to be genuinely contrite. I understand why you stay with your partner." C.) "You both need to see a counselor to figure this out. Your partner will go if your partner truly loves you." D.) "Although your partner seems sorry, often an abuser will continue to repeat the behavior in the future."
Answer: D.) "Although your partner seems sorry, often an abuser will continue to repeat the behavior in the future."