Mental Health Care for Survivors of Violence

violence

a national health problem

follow-up efforts in elder abuse goal (evaluation and treatment outcomes)

end abuse and keep individual in own living arrangement

evidence-based nursing care for persons experiencing violence

survivors of violence and abuse can be encountered in many health care settings

special concerns for victims of sexual assault: *assessment topics*

the purpose is twofold: - to assess the patient for injuries - to collect evidence for forensic evaluation and proceedings

cyberstalking

use of the internet, e-mail, or other telecommunications technology

psychological abuse (child abuse)

- verbal abuse - other subtle forms

treatment for the abuser

1) Court mandated, often outpatient groups 2) States vary on requiring programs 3) Must be culturally sensitive 4) May require abusers to undergo substance abuse treatment concurrently - required to remain sober - random drug testing

Answer: A 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.

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."

"date-rape" drugs (rape and sexual assault)

adolescents and young adults

sexual assault

any form of non consenting sexual activity

acts of commission (child abuse)

intentional harmful behaviors: physical, sexual, and psychological abuse

establishing a therapeutic relationship

most important step in caring for person

nonconsensual sex within a marriage...

no longer an exemption for rape and sexual assault

risk factors for abuse of older adults

older age, impaired ADLs, cognitive disability, dependency on caregiver, isolation, stressful events, history of intergenerational conflict

coping with anxiety (nursing interventions)

- anxiety management crucial intervention for all survivors - need to know how to soothe themselves when experience painful feelings - most survivors struggle with control issues - skills offer one way to maintain some control over their bodies and choices

physical abuse (intimate partner violence)

- any act of aggression with or without use of an object or weapon - behavior becomes a pattern that increases in severity - contributes to other health problems - women more likely to be seriously injured or killed

theories of violence: social learning theory (intergenerational transmission of violence)

- children witnessing violence in homes often perpetrate violent behavior in families as adults - learn to accept violence and expect it - learned behavior is reinforced within social systems or when inadequate social or legal constraints to discourage behavior

theories of violence: economic disadvantage, community disorganization, attitudes supportive of violence

- community disorganization and weak social control leads to increased levels of crime and IPV - institutions which foster social control lose ability to exercise social control - foster individual acceptance of violence → increased rates of IPV, child abuse, elder abuse

acts of omission (child abuse)

- considered child neglect - not meeting physical, emotional, educational, and health care needs - most common form

evaluation and treatment outcomes

- criteria depends on setting for interventions - evaluation of nursing care for abused children depends on attaining goals mutually set with parents or guardians - eliminate all violence = ultimate goal - may see smaller goals reached first while working toward ultimate goal - follow-up efforts in elder abuse - appropriate treatment of any disorder resulting from abuse - measure gains in small steps

psychological abuse (intimate partner violence)

- criticize, insult, humiliate, or ridicule; destroy another's property; threaten or harm pets; control or monitor spending and activities; or isolate person from family or friends - more constant than physical violence - perpetrator downplays consequences - often blames victim

psychoeducation checklist: abuse

- cycle of violence - access to shelters - legal services - government benefits - support network - symptoms of anxiety, dissociation, and PTSD - safety or escape plan - relaxation - adequate nutrition and exercise - sleep hygiene - HIV testing and counseling

safety assessment (evidence-based nursing care for persons experiencing violence)

- determine if survivor is in danger - determine if any children in home and their danger risk - Danger Assessment Screen - Danger Assessment-5 (abbreviated version)

a victim of prolonged sexual abuse will: (child abuse)

- develop low self-esteem, a feeling of worthlessness, and a distorted view of sex - become withdrawn, distrustful, or suicidal - show an unusual interest in or avoidance of sexually related content, seductiveness, refusal to go to school, delinquency, secretiveness, and unusual aggressiveness

high risk factors for those more likely to abuse (abuse of older adults)

- drugs or alcohol - high levels of stress - lack of social support - high emotional or financial dependence on the older adult - lack of training in providing care for older adult - depression

therapeutic communication (establishing a therapeutic relationship)

- establish rapport - start with least sensitive topics working toward most sensitive topics - ensure confidentiality - supportive, empathetic approach most effective - must make clear responsibility of mandatory reporting

psychosocial assessment (evidence-based nursing care for persons experiencing violence)

- fear - low self-esteem - guilt and shame - problems with intimacy - revictimization - social networks - social isolation - economic and emotional dependency

appropriate treatment of any disorder resulting from abuse (evaluation and treatment outcomes)

- follow-up nursing assessments - ultimate outcome to end violence and enable survivor to return to more productive life

theories of violence: imbalances in relationship power

- gender - patriarchal systems - limited women right's - The Violence Against Women Act (1994) - cultural norms - religious norms

safety issues and mandatory reporting (theories of violence)

- health care providers are mandated reporters - mandatory reporting is controversial, may act as barrier to disclosure - all states require reporting of known or suspected abuse of children and vulnerable adults - nurses must be familiar with state law and organization policies - may be necessary to remove victims from families or caregivers if necessary - decision made by professional team, not one individual - if older adult is competent, must be allowed an appropriate degree of autonomy even if decides to stay with abuser - forcing adult to do something against his or her will is form a victimization

safety planning (nursing interventions)

- help survivor recognize signs of danger - devise plan to escape: mapping escape route, packed and hidden bag of essentials - make arrangements to get children out safely - child or dependent elder: safe place to hide and important phone numbers

domestic (family) violence: most common (type of violence and abuse)

- intimate partner violence (IPV) - child abuse - child neglect - abuse of Older Adults

working with children (nursing interventions)

- learn "violence vocabulary" - learn that violence is not their fault - allow communication in supportive, caring relationship - respond with sensitivity, belief, and calm demeanor - avoid pressuring to talk or share details if uncomfortable - use play to react abuse - teach strategies to manage fear and anxiety

perpetrator (rape and sexual assault)

- majority are men; in women, sexual assault of children or statutory offenses are more likely - victim often knows this person

tension building (phase I in cycle of violence)

- minor incidents - perpetrator establishes total control of victim by psychological and emotional means - perpetrator demands total acquiescence of victim. verbal abuse and accusations follow - perpetrator isolates victim by approving/disapproving social contacts - perpetrator monitors victim's activities, phone calls, mall, and travels and demands explanations - perpetrator degrades and demoralizes victim by scrutinizing victim's physical and mental characteristics (unattractive, stupid) and functions and assaulting victim's self-esteem (worthless, "no good")

rape

- most severe form of sexual assault - crime of violence - anyone of any age - majority reported are in female victims - adolescents and young adults most vulnerable - Native American or Alaskan Native - multiracial women experienced higher rates - men are less likely to report

psychosocial interventions (nursing interventions)

- must address guilt, shame, and stigmatization survivors will be experiencing - assist survivors to verbalize their experience - directly challenge self-blame - help survivors to identify strengths and validate thoughts and feelings

parent factors (child abuse)

- young, without social support, resources, knowledge - multiple stressors, emotional or substance abuse, harsh punish

risk factors for intimate partner violence

- occurs across all demographics and socioeconomic levels - *highest risks among*: younger women, women who are divorced or separated, Native American and Alaska Native women - nonheterosexual couples are also victims, however, receive less support due to social stigma - frequent conflicts, jealousy, possessiveness increase risk of violence - *individual characteristics*: low self-esteem, emotional insecurity, depression, antisocial or borderline personality traits, history of violence - substance abuse - presence of firearms - personal stressors - pregnancy

abuse or neglect of older adults

- older than age 60 years - physical - sexual - emotional - neglect - abandonment - financial

managing anger (nursing interventions)

- part of healing process - teach anger management techniques - recognize anger and express it assertively - own the feeling by using "I feel" and avoid blaming others - teach children anger management and conflict resolution

effects of violence

- permanent changes in survivor's reality and meaning of life - deep wounds - endangerment of core beliefs about self, others, and the world - damage or destruction of survivor's self-esteem

remorse ensues (phase III of cycle of violence)

- perpetrator becomes kind, contrite, and loving- begging for forgiveness and promising never to inflict abuse again (until next time) - tension builds; the cycle repeats

goals of nursing interventions

- prevent injury - stop the violence - ensure survivor's safety - restore health - should empower survivors to act on their own behalf - must be collaborative partnership with survivor making the final decision depending on age and situation

physical health intervention (nursing interventions)

- properly treat trauma - provide proper treatment for malnourishment and/or dehydration - provide proper interventions for victims of sexual abuse - need to provide for basic needs first before addressing psychological trauma - promote healthy daily activities: sleep, exercise, leisure time, nutrition - managing care of patients with mental health or substance abuse issues - refer to appropriate treatment centers

finding strength and hope (nursing interventions)

- providing hope and sense of control fundamental for survivors - assist survivor to identify specific strengths and aspects of lives that are under their control - may empower survivor to find options and leave abusive situation - encourage and create opportunities for survivors to make live decisions

community involvement (nursing interventions)

- reduce violence at community level - develop support networks - home visits - due to potential danger to nurse, carefully consider home visits before proceeding, take appropriate action, such as meeting the survivor in a safe place

goals for nurse in nursing interventions

- remain nonjudgmental - provide information of available services and emergency contact information - if older adult unable to make decisions, may need guardianship, foster care, or nursing home placement - nurse should initiate referral to appropriate person to facilitate further interventions

stalking

- repeated unwanted contact, attention, and harassment often increases in frequency - crime of intimidation - cyberstalking - may include such behaviors as following someone, showing up at the person's home or workplace, vandalizing property, or sending unwanted gifts - 1 in 6 women; 1 in 19 men experience this in their lifetime

mental health nursing assessment (evidence-based nursing care for persons experiencing violence)

- safety assessment - screening for violence and abuse - physical health assessment - psychosocial assessment

violence erupts (phase II of cycle of violence)

- severe injury to victim and children - victim may incite violence as a way to control mounting terror - period of relative calm follows battering

intimate partner violence

- significant public health problem - psychological (emotional), physical, stalking, or sexual harm by current or former spouse, significant other, dating partner - victims: estimated 1 in 4 women; 1 in 10 men - results in billions of dollars in costs - approximately 63% of female murder victims killed by current or former intimate partners - physical abuse - psychological abuse - teen partner abuse - comorbidities - risk factors

teen partner abuse (intimate partner violence)

- survey found 12% of girls and 7% of boys reported abuse by dating partner - conflict or relationship problems with parents or peers may be predictive - teens who experience abuse more likely to develop: depression, substance abuse, eating disorders, thoughts of suicide

measure gains in small steps (evaluation and treatment outcomes)

- survivor must be ready to make changes - easy to become angry or discouraged when working survivors - always protect confidentiality of survivor

comorbidities (intimate partner violence)

- survivors can suffer multiple conditions besides injuries and death from IPV - anxiety disorders, depression, PTSD, substance abuse disorder - various health problems: asthma, gastrointestinal conditions, cardiovascular problems, bladder infections, migraines, joint pain, gynecologic disorders, STDs, traumatic brain injuries

psychoeducation (nursing interventions)

- teach self-protection skills, healthy relationship skills, and healthy sexuality - especially important for children - information about resources: shelters, legal services, government benefits, support networks - use caution when giving individual written material, especially if still with abuser

managing care of patients with mental health or substance abuse issues (physical health nursing interventions)

- trauma-informed cognitive-behavioral therapy - interpersonal therapy specifically targeting psychological consequences of IPV

power and control (intimate partner violence)

- using coercion and threats - using intimidation - using emotional abuse - using isolation - minimizing, denying and blaming - using children - using male priviledge - using economic abuse

priority of nursing care

- violence and abuse are critical situations that need to be addressed immediately - nurse needs to focus on individual's personal safety first - ensure any injuries are treated promptly

physical health assessment (evidence-based nursing care for persons experiencing violence)

1) Complete history and physical examination 2) Note vital signs, sleep and appetite disturbances, exaggerated startle response, flashbacks, nightmares 3) Assess injuries in need of immediate attention 4) Use body map to note injuries 5) Documentation may become evidence in court 6) May be evidence of mild to severe physical consequences 7) Examination for sexual abuse may require referral to a trained RN in sexual assault (SANE) 8) Determine need for emergency contraception or prophylactic treatment for STDs 9) Special concerns for victims of sexual assault 10) Healthy child development/deviation 11) Assess developmental milestones, school history, relationships with siblings and friends 12) Discrepancies between history, physical examination, implausible explanations for injuries/symptoms should be an alert for possible abuse 13) Be familiar with normal aging and signs and symptoms of common illnesses in older adults 14) Signs of malnutrition or inattention to ADLs 15) Inconsistent explanations for bruises, lacerations, and other injuries 16) Evidence of excessive medication or physical restraints 17) History and Physical Findings Suggestive of Abuse

danger assessment screen

1) Has the physical violence increased in frequency during the past year? 2) Has the physical violence increased in severity during the past year or has a weapon or threat with weapon been used? 3) Does your partner ever try to choke you? 4) Is there a gun in the house? 5) Has your partner ever forced you to have sex when you did not wish to do so? 6) Does your partner use drugs? By drugs, I mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack," street drugs, heroin, or mixtures. 7) Does your partner threaten to kill you, or do you believe he or she is capable of killing you? 8) Is your partner drunk every day or almost every day? (In terms of quantity of alcohol.) 9) Does your partner control most or all of your daily activities? For instance, does he or she tell you who you can be friends with, how much money you can take with you shopping, or when you can take the car? 10) Has your partner ever beaten you while you were pregnant? (If never pregnant by him, check here __________) 11) Is your partner violently and constantly jealous of you? (For instance, does he or she say, "If I can't have you, no one can.") 12) Have you ever threatened or tried to commit suicide? 13) Has he ever threatened or tried to commit suicide? 14) Is your partner violent toward the children? 15) Is your partner violent outside the home?

special concerns for victims of sexual assault: *key interventions*

1) Prevention of short- or long-term psychopathology after sexual assault is crucial 2) Psychological trauma after rape and sexual assault includes immediate anxiety and distress and the development of PTSD, depression, panic, and substance abuse. 3) Early treatment because initial levels of distress are strongly related to later levels of posttraumatic stress disorder, panic, and anxiety. 4) Supportive, caring, and nonjudgmental nursing interventions during the forensic rape examination are also crucial. This examination often increases survivors' immediate distress because they must recount the assault in detail and submit to an invasive pelvic or anal examination. 5) Anxiety-reducing education, counseling, and emotional support, particularly in regard to unwanted pregnancies and sexually transmitted infections, including HIV. All survivors should be tested for these possibilities. Treatment may include terminating a pregnancy; administering medications to treat gonorrhea, chlamydia, trichomoniasis, and syphilis; and administering medications that may decrease the likelihood of contracting HIV infection. 6) Interventions that are helpful for survivors of domestic violence; these also apply to survivors of sexual assault.

theories of violence

1) Social Learning Theory (Intergenerational Transmission of Violence) 2) Economic Disadvantage, Community Disorganization, and Attitudes Supportive of Violence 3) Imbalances in Relationship Power 4) Cycle of Violence 5) Factors Influencing Leaving versus Staying in a Violent Relationship 6) Safety Issues and Mandatory Reporting

factors influencing leaving versus staying (theories of violence)

1) fear of retaliation 2) continue to hold strong feelings for abuser 3) critical to remain nonjudgmental; realize victim has valid reasons for staying 4) very complex to leave the relationship: - may leave and return several times while developing coping skills - lack job skills, financial resources, support systems - afraid of losing custody of children - fear of threats against other family members - leaving does not stop violence: stalking, escalation of violence, may result in death of victim; presents time of greatest risk

family interventions (nursing interventions)

1) in child abuse, focus on behavioral approaches to improve parenting skills - child management skills - parenting skills - leisure skills - household organization 2) anger control and stress management skills

screening for violence and abuse (evidence-based nursing care for persons experiencing violence)

1) universal screening for all women of child-bearing age highly recommended 2) survivors reluctant to report abuse due to fear 3) if suspected abuser is present, important to speak to survivor alone 4) various screening tools available 5) nurse needs age-appropriate, culturally sensitive abuse-related questions ready 6) provide privacy and time to allow survivor to tell their story 7) nurse should not offer unsolicited advice or make judgmental remarks 8) use validated messages to convey belief in survivor 9) avoid pressuring or confronting survivor 10) carefully document description using survivor's own words 11) after assessment is complete, offer adult survivor use of telephone 12) schedule future appointments to provide survivor legitimate reason to leave

Answer: A 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.

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.

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.

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: B 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.

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: D 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.

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.

Answer: C 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.

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: A 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.

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,B,D Rationale: When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

15. In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (Select all that apply.) A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by abuse between their parents. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay.

Answer: A,B Rationale: An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. 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.

16. Which of the following nursing diagnoses are typically appropriate for an adult survivor of incest? (Select all that apply.) A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Non-adherence

Answer: A,B,D Rationale: Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. It is used to gain power and control over the other intimate partner. Women ages 25 to 34 experience the highest per capita rates of intimate violence. Eighty-five percent of victims of intimate violence are women. Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups. They may be married or single, housewives or business executives.

17. A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (Select all that apply.) A. "Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner." B. "Intimate partner violence is used to gain power and control over the other intimate partner." C. "Fifty-one percent of victims of intimate violence are women." D. "Women ages 25 to 34 experience the highest per capita rates of intimate violence." E. "Victims are typically young married women who are dependent housewives."

Answer: 2,1,3 Rationale: In her classic studies of battered women and their relationships, Walker identified a cycle of predictable behaviors that are repeated over time. The behaviors can be divided into three distinct phases that vary in time and intensity both within the same relationship and among different couples. 1. Tension building phase. In this phase, the man's tolerance for frustration is declining. 2. Acute battering incident phase. This phase is the most violent and the shortest, usually lasting up to 24 hours. 3. Honeymoon phase. In this phase, the batterer becomes extremely loving, kind, and contrite.

18. Order the description of the progressive phases of Walker's model of the "cycle of battering?" ________ This phase is the most violent and the shortest, usually lasting up to 24 hours. ________ In this phase, the man's tolerance for frustration is declining. ________ In this phase, the batterer becomes extremely loving, kind, and contrite.

Answer: D 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.

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.

Answer: A 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.

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: B 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.

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 further, detailed description of the rape event.

Answer: C 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.

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: D 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.

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: C 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.

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: C 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.

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."

highest risk for child abuse

< 4 years old, products of unwanted pregnancy, developmental or physical disability

*The nurse is working with a 29-year-old female who is a victim of IPV. Which factor must the nurse prioritize when providing care to this patient?* A. Remain nonjudgmental throughout the process B. Convince the individual to make changes C. Refuse to continue working with the survivor D. Press charges against the abuser

A

*Which type of crime is rape considered?* A. Violence B. Intimidation C. Power D. Anger

A

When asked, the nurse stated that the two women were lesbians, so she did not need to screen them. What response by the manager is best? A. "Lesbians who are in intimate relationships are considered intimate partners." B. "There is a specific screening tool just for lesbians and homosexuals." C. "You have to screen all women for IPV regardless of their sexual preference." D. "You're right; lesbians have a far lower rate of IPV than heterosexuals do."

Ans: A Rationale: Intimate partners are described as "current and former husbands and wives, same-sex partners, boyfriends, and girlfriends," so the nurse should screen these patients too.There is no specific screening tool for same-sex partners.The policy may be to screen all patients, but this statement does not give the nurse specific information about this situation

The nurse is caring for a patient whom the nurse suspects is a victim of intimate partner violence (IPV). What screening question made by the nurse is most appropriate? A. "Can you tell me how you got your injuries?" B. "Can you tell me if it is safe for you to go home?" C. "Can you tell me what you know about intimate partner violence?" D. "Can you tell me what your spouse was doing when you sustained your injuries?"

Ans: B Rationale: Screening is one way that nurses can help to provide information and resources to a person who may be suffering IPV. The most appropriate way to screen for IPV is the use of direct questions about the violence. The most appropriate question is, "Is it safe for you to go home?" All the other questions are not as direct, and they do not get at the priority nursing action, which is to assess the safety of the patient.

*Which factor should a nurse prioritize assessing in a survivor of violence?* A. Social support B. Lethality C. Mental status D. Dependency in the relationship

B

cycle of violence

Phase I - Tension Building Phase II - Violence Erupts Phase III - Remorse Ensues

*True/False*: During the second phase of the cycle of violence, the perpetrator experiences a period of intense upset after the violent incident occurs.

false

*True/False*: IPV is not considered a risk for individuals in the highest socioeconomic levels.

false

results in children (child abuse)

physical, emotional, and behavioral problems