PU Unit III

A 2-year-old child is brought to the emergency department with a broken arm. Which finding should lead the nurse to suspect child abuse? a) The child's clothes are dirty, torn, and obviously "hand-me-downs." b) The child's father alters the story of the injury each time he tells it. c) The child's mother does not come to the hospital with the child. d) The child has bruises on the forearms.

b

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? a) Do nothing because the nurse has no proof of wrongdoing. b) Monitor the situation during subsequent visits. c) Report the suspicion to the local agency on aging within 24 hours of the visit. d) Try to convince the client to report the problem.

c

An 16-year-old male is admitted to the facility after acting out his aggressions inappropriately at school. To better understand possible contributing factors, the nurse should assess for: a) passive parents. b) a single-parent family. c) viewing of televised violence. d) an internal locus of control.

c

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which of the following is a correct component in the nursing plan of care? a) Protecting the client's safety by completing an incident or occurrence report b) Documenting the situation and providing support for the victim c) Counseling the victim d) Counseling the person committing the abuse

b

Which questions that the nurse asks a client suspected of being abused would most encourage her to admit and describe her abuse? a) "When were you in an accident?" b) "How long have you had these bruises?" c) "Who is doing this to you?" d) "How did you hurt yourself?"

c

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which of the following is a correct component in the nursing plan of care? a) Documenting the situation and providing support for the victim b) Counseling the victim c) Counseling the person committing the abuse d) Protecting the client's safety by completing an incident or occurrence report

a

A child is brought to the clinic by a grandparent who states that someone may have sexually abused the child. The grandparent noticed blood and a discharge on the child's underpants. After the child is assessed and treated for injuries, which of the following is the priority intervention by the nurse? a) Reporting the suspicion to the appropriate authorities b) Telling the grandparent that the child cannot be treated without parental permission c) Calling the parents and inform them that someone has molested the child d) Having the office manager notify the police

a

The parent of a school-aged child tells the nurse that, "For most of the past year, my husband was unemployed and I worked a second job. Twice during the year I spanked my son repeatedly when he refused to obey. It has not happened again. Our family is back to normal." After assessing the family, the nurse decides that the child is still at risk for abuse. Which observation best supports this conclusion? a) The child wears long sleeve shirts and long pants, even in warm weather. b) The parents say they are taking away privileges when their son refuses to obey. c) The child has talked about family activities with the nurse. d) The parents are less negative toward the nurse.

a

When the nurse asks a child suspected of being physically abused how his shoulder was hurt, he replies, "It was my fault. I was bad." What would be the nurse's best response? a) "Perhaps it was not your fault. Can we talk about what happened?" b) "You will have to behave better so this will not happen again." c) "Tell me what you did that made your father hurt you." d) "We will make you better, and we will not let your father do this to you again."

a

A client suspected of being a victim of abuse returns to the emergency department and, sobbing, tells the nurse, "I guess you really know that my husband beats me and that is why I have bruises all over my body. I do not know what to do. I am afraid he will kill me one of these times." Which response best demonstrates that the nurse recognizes the client's needs at this time? a) "We can begin by listing ways to avoid making your husband angry with you." b) "We can begin by discussing various options open to you." c) "You can legally leave your husband because he has no right to hurt you." d) "The fear that your husband will kill you is unfounded."

b

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: a) contacting the local children's protective service office with an anonymous tip. b) ensuring that the suspected child abuse is reported to local authorities. c) contacting the infant's next of kin to begin discharge planning. d) reporting her suspicions to the hospital's chief of pediatric services.

b

The nurse is educating parents of first graders about child sex abuse. What is the most critical information the nurse should convey to the parents? a) One parent is often aware that sexual abuse is occurring. b) Children are willing to tell parents about the abuse if parents ask. c) An adult who abuses a child is usually known to the child. d) Most cases of child sexual abuse are committed by strangers.

c

Choice Multiple question - Select all answer choices that apply. When working with a group of adult survivors of childhood sexual abuse, dealing with anger and rage is a major focus. Which strategy should the nurse expect to be successful? Select all that apply. a) keeping a journal of memories and feelings b) writing letters to the adults who did not protect them but not sending them c) using a foam bat while symbolically confronting the abuser d) directly confronting the abuser e) writing letters to the abusers but not sending them

a b c e

Choice Multiple question - Select all answer choices that apply. A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic(s)? Select all that apply. a) guilt b) self-blame c) assertiveness d) suicidal thoughts e) alcohol abuse

a b d e

Choice Multiple question - Select all answer choices that apply. A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate? Select all that apply. a) Clients with PTSD may complain of feeling empty inside. b) PTSD is a syndrome that affects only those who have experienced traumatic episodes during war. c) Psychotic episodes can occur in clients with PTSD. d) PTSD is characterized by nightmares and flashbacks. e) Substance abuse is a common coping mechanism used by clients with PTSD. f) Hypervigilance is characteristic of clients with PTSD.

a c d e f

A nurse is counseling a married woman who has two children under 4 years of age and is a victim of spousal abuse. Before the client leaves the clinic, what is the most important thing the nurse should do? a) Teach the client about the cycle of violence. b) Discuss the abuser's behaviors with the client. c) Help the client develop a safety plan. d) Give the client the name of a domestic violence shelter.

c

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? a) reporting the abuse to a prosecutor b) giving the child's drawings to the abuser c) engaging in play therapy d) role-playing

c

During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which response would the nurse find inconsistent with the profile of a battered partner? a) "I love my husband and will help him." b) "I am not sure I could get a job that pays even minimum wage." c) "The abuse adds spice to our relationship." d) "I am responsible for keeping my family together."

c

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers? a) bribery with money b) asking for the child's consent for sex c) coercion as a result of the trusting relationship d) tying the child down

c

The nurse is caring for a 5-year-old child who has a history of multiple admissions for fractures and cuts. The mother explains that the child fractured the femur by falling, but does not give any further details. The child indicates that the mother's boyfriend was present when the injury occurred, and the child's recollection of the event conflicts with the mother's explanation. What is the nurse's immediate responsibility? a) Collect forensic specimens for laboratory analysis. b) Restrict family who are visiting the child. c) Keep the child safe and assess for abuse. d) Call the police department and report abuse.

c

When preparing to present a community program about women who are victims of physical abuse, which should the nurse stress about the incidence of battering? a) Physical abuse typically begins early in a relationship well before a women gets pregnant. b) Lower socioeconomic groups are primarily affected. c) Battering is a major cause of injury to women. d) Death from battering is rare.

c

After a client reveals a history of childhood sexual abuse, what question should the nurse ask first? a) "Does your abuser still have contact with young children?" b) "What other forms of abuse did you experience?" c) "Was there a time when you did not remember the abuse?" d) "How long did the abuse go on?"

a

A client who is a victim of domestic violence tells the nurse she is contemplating leaving the relationship. Which assessment should be a priority for the nurse? a) Readiness to leave the perpetrator and knowledge of helpful resources b) Reasons for remaining in the abusive relationship c) Use of drugs or alcohol to cope with victimization d) History of previous victimization

a

A nurse discusses an abused client and her family in a staff meeting. Which statement made by other staff members is likely to be most helpful to the nurse in developing a treatment plan? a) "Suggest that she attend a group for battered women." b) "Tell her to leave her husband immediately." c) "Call the client's mother to find out what she knows about the abuser." d) "This client sounds like a lot of women I know who do not want to change."

a

A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint? a) "Sometimes my husband gets so angry with me." b) "I'm going to need help at home after I'm discharged." c) "I'm so clumsy." d) "I'm afraid I'll lose my job because I'm going to miss so much work."

a

Which statement about the initial care of a suspected abuse victim, when documented on the chart, would be most helpful for others when caring for the client? a) "Seems fearful to discuss how bruises on her body had been caused." b) "Asks that her husband not be called at work, stating that he is very busy." c) "States that she is not employed outside the home." d) "Refuses a follow-up appointment, stating that she does not have time."

a

Choice Multiple question - Select all answer choices that apply. Which nursing action is appropriate when planning care for a client who is being battered? Select all that apply. a) Teach the client about the cycle of violence. b) Give information about a safe home. c) Discuss the client's legal and personal rights. d) Provide a cell phone and the crisis help line telephone number. e) Help the client displace her feelings.

a b c d

Choice Multiple question - Select all answer choices that apply. A nurse is working in the emergency room when a police officer walks in with a rape victim to be examined. If the nursing goal is to reduce client anxiety, which interventions would be appropriate? Select all that apply. a) Ask factual questions to determine the type of assault. b) Allow a third party to be present if the client requests it. c) Assure the client of safety in the examination room. d) Touch the client early on demonstrating the nurse is supportive. e) Admit the client to the treatment area right away. f) Encourage the client to undergo an examination immediately in order to get it behind her.

a b c e

Choice Multiple question - Select all answer choices that apply. A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her injuries is complete, and she is ready for discharge. What should the nurse do to ensure the woman's safety and security prior to discharge? Select all that apply. a) Provide information on resources and a safety plan. b) Ask if she plans to see the ex-boyfriend again. c) Determine if the client knows the location of the ex-boyfriend. d) Obtain consent to send her emergency department records to her family health care provider (HCP). e) Ensure that she has a safe place to stay after discharge.

a b c e

A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. To assess for the likelihood of further violence and abuse, the nurse should determine that the husband: a) trusts his wife and supports her independence. b) has learned violence as an acceptable behavior. c) feels secure in his relationship with his wife. d) has moderate impulse control.

b

A nurse discusses an abused client and her family in a staff meeting. Which statement made by other staff members is likely to be most helpful to the nurse in developing a treatment plan? a) "Call the client's mother to find out what she knows about the abuser." b) "Suggest that she attend a group for battered women." c) "This client sounds like a lot of women I know who do not want to change." d) "Tell her to leave her husband immediately."

b

A client is admitted to the medical unit with complaints of extreme fatigue and chest pain. An electrocardiogram has ruled out any cardiac involvement and laboratory work indicates that the client is experiencing severe hypothyroidism. As the nurse interviews him, the client states that he has been feeling very sad and depressed about the changes in his body and wonders if there's any reason to go on. The nurse should: a) tell the client his feelings are a result of hypothyroidism and will abate soon. b) tell the client that a psychiatrist will come talk to him. c) tell the client he has nothing to worry about because this physicians can successfully treat this condition. d) ask if the client has thought about wanting to harm himself.

d

A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The client describes her husband's upbringing as chaotic. The nurse caring for this client understands that this situation is consistent with which fact about family violence: a) Violent behavior is a genetic trait passed from one generation to the next. b) Violence usually results from a power struggle. c) Open boundaries are common in violent families. d) Domestic violence and abuse span all socioeconomic classes.

d

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Document the bruising and continue to assess the area over the next 72 hours. b) Report this finding to the nurse who is taking care of the client. c) Report this finding to the physician. d) Report this finding to the Adult Protective Services (APS).

d

After talking with the nurse, a client admits to being physically abused by her husband. She says that she has never called the police because her husband has threatened to kill her if she does. She says, "I do not want to get him into trouble, because he is the father of my children. I do not know what to do!" Which nursing intervention would be most therapeutic at this time? a) Tell the client that she should leave her husband. b) Help the client identify the behaviors that provoke the abuse. c) Teach the client ways to reduce stress within her family. d) Express concern for the client's safety.

d

During an assessment interview, a depressed 15-year-old girl states that she "can't sleep at night." The nurse begins to explore factors that might contribute to this situation by asking if the girl is sexually active. The girl changes the subject. What should the nurse suspect based on the client's response to the assessment question? a) Spiritual distress b) Somatic symptom disorder c) Narcolepsy d) Sexual abuse

d

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation? a) Confront the mother by asking her what she's doing and why. b) Leave the room immediately, without the neonate, and notify the nursing supervisor. c) Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior. d) Return the neonate to the nursery, inform the physician so he can thoroughly examine the neonate for injuries, and notify social services for assistance.

d

choice Multiple question - Select all answer choices that apply. A client who lives with his spouse and two adolescent children is being treated for alcoholism. After a family meeting, the client's wife asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. Which organizations should the nurse suggest that the family join? Select all that apply. a) Alateen b) Make Today Count c) Emotions Anonymous d) Al-Anon e) Alcoholics Anonymous

a d

A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next? a) Ask the client specifically about the possibility of physical abuse. b) Ask the client what she did to make someone beat her so badly. c) Discuss with the client what she can do to de-escalate the situation next time. d) Tell the client that it is difficult to believe that such injuries resulted from a fall.

a

A nurse is planning interventions for a victim of physical abuse. On what principle should the nurse base the plan? a) Assessing the client's level of danger is a prerequisite to intervention. b) A woman in crisis is unlikely to be receptive to professional help. c) The client generally can control the batterer. d) The victim will want to leave the abuser immediately.

a

A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, "All this work with her has been useless. She is just going back to him as usual." Which statement by a nursing colleague would be most helpful to this nurse? a) "You did your best. You will see her again and have another chance." b) "Her reasons for staying are complex. She can leave only when she is ready and can be safe." c) "I know it is frustrating to work with clients who do not follow our advice." d) "These women almost never leave for good because of their emotional and financial dependency."

b

A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? a) Tell the husband that he must leave because he is intimidating the client. b) Collaborate with the physician to make a referral to social services. c) Question the woman in front of her husband. d) Contact hospital security to escort the husband from the hospital.

b

When the nurse asks a child suspected of being physically abused how his shoulder was hurt, he replies, "It was my fault. I was bad." What would be the nurse's best response? a) "Tell me what you did that made your father hurt you." b) "We will make you better, and we will not let your father do this to you again." c) "You will have to behave better so this will not happen again." d) "Perhaps it was not your fault. Can we talk about what happened?"

d