Violence/ Trauma study questions

A child is prescribed 375 mg of ampicillin orally every 6 hours. Ampicillin liquid is available in 250 mg per 5ml. How many milliliters should be given per dose?

7.5

The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client? A) Assist the client to devise a safety or escape plan. B) Encourage the client to take charge of the situation. C) Offer to contact outpatient services if the client promises not to return home after discharge. D) Make it clear to the spouse that the couple needs to see a therapist.

Answer: A Explanation: A client who has been victimized by a partner should have a safety plan. This has the highest priority as the client's life is in danger. The client has no control over the partner, and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging the client to take charge is too general a statement to be helpful; the client needs specific tools to develop a safety plan. It may not be safe and feasible for the client to leave the situation right away, and resources should not be withheld if a client is unable to promise not to return home.

After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next? A) Conducting a team assessment B) Medicating for anxiety as prescribed C) Notifying the police D) Treating the injuries

Answer: A Explanation: If the nursing assessment reveals possible domestic violence, a primary focus will be treating the injuries. However, treatment is often done by a team, which means a team assessment needs to be conducted before treatment can take place. The police may need to be notified later. The degree of anxiety will determine whether the client needs medication.

Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain? A) Ultrasound B) X-ray C) MRI D) Blood test

Answer: A Explanation: An ultrasound or CT scan of the abdomen can check for abdominal or organ injuries. An MRI of the spine will show spinal injuries. X-rays can detect fractured bones. Blood tests may be used to detect sexually transmitted diseases.

A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate? A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem

Answer: A Explanation: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.

Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors? A) Social learning theory B) Psychopathology theory C) Neurobiology theory D) Environmental theory

Answer: A Explanation: Social learning theory explains that individuals learn violent tendencies through association with others and a reinforcement of the abusive behavior. Psychopathology theory suggests that some individuals who experience personality disorders and mental illnesses participate in family violence as a result of these illnesses. Neurobiology theory asserts that genetics plays a role in anger modulation and emotion control. Environmental theory is not related to the etiology of abuse.

An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply. A) Poor hygiene B) Dehydration C) Intracranial trauma D) Fecal impaction E) Dislocations

Answer: A, B, D, E Explanation: The nurse suspecting elder abuse would assess for clinical manifestations associated with elder abuse. Some of those clinical manifestations are constant hunger or malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it is a clinical manifestation of child abuse.

The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply. A) Involvement in the community B) Participation in family activities C) Residing in an impoverished community D) Academic failures at a young age E) Success in school

Answer: A, B, E Explanation: Involvement in the community, participation in family activities, and success in school are all examples of protective factors. Protective factors decrease the risk of violence perpetration and victimization. Residing in an impoverished community is a predisposing factor. Academic failure at a young age is a risk factor for becoming a perpetrator.

The nurse is caring for several clients in the emergency department. Which individual is a victim of community violence? A) A 32-year-old woman who was beaten by her spouse B) A 20-year-old man who was shot during a gang dispute C) A 6-month-old girl who was abused by her mother D) A 76-year-old man who was neglected at a care facility

Answer: B Explanation: Gang violence is a type of community violence, so traumatic injuries sustained during a gang dispute would be categorized as community violence. The other examples are related to interpersonal violence.

What type of communication should the nurse employ when caring for a client who has suffered trauma? A) Assertive communication B) Therapeutic communication C) Passive communication D) Aggressive communication

Answer: B Explanation: Nurses need to employ therapeutic communication to help clients work through the stress and fear of the traumatic event and ultimately accept that the situation they experienced cannot be reversed. Nurses should never use passive or aggressive communication techniques with clients. Assertive communication may be helpful in some circumstances, but it is not as important as therapeutic communication.

A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective? A) "Everyone knows what my problems are, and there is nothing I can do about it." B) "I am functioning fine now but I know that when problems come up again, I will ask for help." C) "My friends tell me that I have improved so this is a good time to stop." D) "It is so draining to deal with the same painful issues all of the time."

Answer: B Explanation: The client acknowledging that future problems will come up indicates that the client has gained insight into problems. The client's willingness to ask for help shows that the client is prepared to continue with counseling when new problems arise. Stating that the process is draining and painful suggests that little progress has been made and that the client is looking to avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of treatment on the statements of others places emphasis on others and not on self-evaluation.

A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply. A) Confusion B) Missing teeth C) Apprehension when other children cry D) Abrasions to the mouth, lips, and genitalia E) Dehydration

Answer: B, C, D Explanation: Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia; missing teeth; and apprehension when other children cry. Dehydration and confusion are manifestations of elder abuse.

A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take? A) Discuss what the nurse witnessed with the infant's mother. B) Discuss what the nurse witnessed with the other nurses. C) Report what the nurse witnessed and assessed to the authorities. D) Call security to remove the father from the room.

Answer: C Explanation: Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant's mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.

Which of the following is a common element of abuse experienced by the victim? A) Accidental injury B) Feelings of control C) Humiliation D) Manipulation

Answer: C Explanation: Common elements of abuse include humiliation, intimidation, and physical injury. Injury associated with abuse is not accidental. Feelings of control and use of manipulation tactics are related to the perpetrator, not the victim.

The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate? A) Contact adult protective services. B) Call the healthcare provider immediately. C) Assess the client's cultural traditions. D) Contact the client's family.

Answer: C Explanation: The most appropriate action for the nurse at this time is to assess the client's cultural traditions. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.

The nurse is discharging a client who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse. The client states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw, we went to Rome." Based on this data, which phase of violence is the client experiencing? A) The tension phase B) The abusive phase C) The honeymoon phase D) The reconciliation phase

Answer: C Explanation: The tension phase of the cycle of violence occurs when communication fails and tension builds. The abusive phase occurs when there is a violent incident. The honeymoon phase occurs when the aggressor shows love and affection. The cycle of violence will continue unless intervention occurs, and there is no reason for the client to expect it will stop or anticipate reconciliation and healing.

A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this data? A) A protective factor B) A risk factor C) A vulnerability factor D) A precipitating factor

Answer: C Explanation: Vulnerability factors increase one's risk of being a victim of violence. The client with a walking disability avoids the possibility of a crime by not going out alone at night. A protective factor decreases the risk of perpetration and victimization. Risk factors increase the potential that one will perpetrate violence on others. Precipitating factors are those that give rise to a specific incident of violence.

A client is brought into the emergency department after being in a motor vehicle crash. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this client? A) Breathing and ventilation B) Circulation with hemorrhage control C) Airway maintenance with cervical spine protection D) Disability and neurologic assessment

Answer: C Explanation: When caring for the trauma victim, the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern be airway maintenance with cervical spine protection.

The nurse is providing care to a child who has suffered abuse. Which nursing actions are appropriate? Select all that apply. A) Ask the child what he did to cause his parents to beat him so badly. B) Tell the child that the individual who hurt them is a bad person. C) Follow protocols for mandatory reporting. D) Remind the child that he did nothing wrong. E) Ask the child what really happened.

Answer: C, D Explanation: The priority nursing consideration regarding the abused child is to ensure the immediate safety of the child. Beyond that, the abused child needs to be encouraged to talk about the abuse but must also be protected from having to provide multiple reports. The nurse working with the abused child needs to say that he or she believes the child's story; the nurse also must reassure the child that he or she has done nothing wrong. The nurse should avoid making negative comments about the abuser and must follow established protocols for mandatory reporting, documentation, and use of available support services.

The nurse is providing care for a 2-year-old client. When assessing the client's risk for abuse, which factors increase this client's risk? Select all that apply. A) The child has bruises on the knees and shins. B) The child's parents are married. C) The child is less than 3 years old. D) The child is deaf. E) The child's parents are unemployed and receive medical assistance.

Answer: C, D, E Explanation: Risk factors for child abuse include poverty, age less than 3 years, and child disability or condition that requires a great deal of care. Marriage of the parents and bruises on the knees and shins are not risk factors for abuse.

A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply. A) Explore options for self-development. B) Improve quality of life by increasing self-esteem. C) Explore options for help. D) Convey safety. E) Determine immediacy of danger.

Answer: C, D, E Explanation: Short-term interventions for abuse include determining the immediacy of danger, conveying that the client has the right to be safe, and exploring options for help. Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults.

An individual who has experienced which type of trauma is likely to be most resilient? A) Intimate partner violence B) Bullying C) Rape D) Natural disaster

Answer: D Explanation: Generally, survivors of natural disasters show resilience, and the stress responses do not become chronic or debilitating. Bullying and intimate partner violence may be ongoing, persistent stressors that prevent resiliency. Rape is an extreme traumatic event that may take months to years to recover from.

A young client is brought into the emergency department by a friend who says the client was "beat up" at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this client? A) The client does not want the individual who did the beating to get in trouble. B) The client does not know his parents. C) The client does not want the school to get in trouble. D) The client is a victim of interpersonal violence.

Answer: D Explanation: The client's reluctance to provide parents' names or address could suggest the client is a victim of child abuse from parents rather than a victim of bullying at school. Either way, the client is clearly a victim of interpersonal violence. It is unlikely that the client does not know his parents. It is also unlikely that the client does not want to get the school or the individual who did the beating in trouble.

The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is present? A) Call the police to have the spouse arrested for assault. B) Refuse to permit the spouse to visit with the client. C) Call security to have the spouse removed. D) Ask the client if there is anything that is needed at this time.

Answer: D Explanation: The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and their family members. The nurse should ask the client if there is anything that is needed at this time. The nurse should not refuse to let the spouse visit unless it is the client's wish to do so. The nurse should not contact security or the police unless requested by the spouse.

The charge nurse hears another nurse, who is giving medications; tell a client that she is unsure of the new medication's action. The charge nurse should: •A. Tell the client what the medicine's action. •B. Ask the nurse to look up the new medicine. •C. Suggest to the nurse not to tell a client when not knowing a drug action. •D. Restrict the nurse from giving medicines for the remainder of the shift.

B

A client on a clear-liquid diet has selected the following beverages from a menu. Which beverage would the nurse remove from the tray? •A. Cranberry juice cocktail. •B. Orange juice. •C. Ginger ale. •D. Iced tea.

B OJ has pulp and is not clear

A client was to be npo after midnight due to morning surgery. The nurse notes that the client received enteral feedings by gastric tube from 12:00 am to 6:00 am at a rate of 120 ml/hour. The operating room has called to premedicate the client. The nurse should: •A. Premedicate the client and send to surgery, as scheduled. •B. Notify the physician. •C. Call the operating room and cancel the surgery. •D. ASk the operating room nurse if the surgery can be rescheduled for later time of day.

B patient can still aspirate, and it is the physician's call

A 48-year-old female client is admitted to a telemetry unit after a syncopal episode. She is married, has two elementary school children, and works for the public defender's office. Her past medical history inclterm-27udes atrial fibrillation, dyspepsia, chronic back pain and a recent urinary tract infection. She denies alcohol or cigarette use and jokes that she is addicted to caffeine. She drinks approximately eight 12-ounce carbonated beverages daily. Her medication list includes warfarin. The client is diagnosed as having probable peptic ulcer disease. The report from the Emergency Department includes the following assessment data: •Alert and oriented X 3 •Speech clear and appropriate •Heart Rate = 104 beats/min •Atrial Fibrillation •Blood Pressure = 99/46 mm HG •Oxygen saturation = 94% (RA) •Denies dizziness or lightheadedness •Reports abdominal discomfort •Stool positive for occult blood and h. pylori bacteria •Hemoglobin = 15 g/dL •Hematocrit = 38% •Inr = 2.5 Based on the previous assessment, which priority questions will the nurse include in an initial assessment? Select all that apply •A. "Are you experiencing burning from your urinary infection?" •B. "How long have you been taking warfarin?" •C. "Does your indigestion keep you from sleeping at night?" •D. "What is the cause of your chronic back Pain?" •E. "Have you ever been told that you need to lose weight?" •F. "When did your abdominal Discomfort start?" •G. "Did you experience cardiac palpations or chest pain before you passed out?" •H. "How many meals do you eat every day?"

B, C, F, G

The nurse evaluates that a victim of rape from 3 months ago needs to continue counseling when she: •A. Continues to talk about the perpetrator. •B. Still feels guilt and anger over the event. •C. Has difficulty falling asleep and awakens at night. •D. Is trying to understand some altered self-perceptions.

C

The nurse of an adult daycare suspects that one of the clients is being abused by the home caregiverterm-32. The next course of action would be to: •A. Validate the findings with other sources. •B. Confront the caregiver. •C. Document the suspicions. •D. Refer the family for counseling.

C Mandated reporter

A client, who was brutally raped and strangled, is brought to the emergency department in cardiac arrest. Although every attempt is made to revive her, the client dies. What should the nurse do while performing care? •A. Remove all tubes and catheters used in the attempt to revive her. •B. Place clothing in a plastic bag and give it to the police. •C. Wrap her hands in paper bags. •D. Wash the body with hot soapy water.

C need to collect evidence

A woman comes to the emergency department with a fractured arm. After long assessment, it is found that her husband is abusing her. The nurse should •A. Discuss with the physician the possibility of an overnight admission. •B. Refer the client and her spouse to couples counseling. •C. Offer information on support groups. •D. Suggest ways in which she can leave her husband as soon as possible.

C no reason to admit her

A rape victim's family asks the nurse how they can help. The nurse evaluates that the family is able to give positive support when they: •A. Use distraction to prevent the victim from thinking about the rape. •B. State concerns about how friends will react to the rape. •C. Listen to the victim identify ways that the rape could have been prevented. •D. Plan ways for the victim to change locks and telephone number.

C patient is identifying what happening and is processing

A woman, who was battered by her husband, is to be discharged. The nurse finds her crying and she states, "I just can't go home with him there." The most appropriate nursing response would be: •A. "Why don't you have a restraining order placed against him?" •B. "Have you discussed this with your doctor?" •C. "you seem frightened about going home." •D. "He is in jail where he can't hurt you."

C therapeutic communication and rephrasing what pt said

During a discharge interview, a client expresses vague suicidal ideations. The nurse confirms that the client is currently suicidal. Place the interventions in the order that the nurse would complete them. •A. Report the situation to the treatment team. •B. Conduct a room search for dangerous objects. •C. Place the client on one-to-one observation. •D. Carefully document the client's observation and the nurse's response.

C, B, A, D

A 9-year-old Boy was brought to the emergency department. His mother said he fell at home and twisted his ankle. An ankle fracture is diagnosed. This injury may be considered suspicious if: •A. The fracture extends through the skin. •B. The bone is splintered into several fragments. •C. A break occurs across the entire section of the bone. •D. The break coils around the bone.

D Twisting may have cause this break

A woman is brought to the emergency department by the police due to an alleged sexual assault. The woman is very quiet, tearful, and does not make eye contact. The client asks if she can just wash up a bit. The nurse should: •A. Take her to private room with a wash basin, clean towels and hospital gown. •B. Ask her to place her clothes in a paper bag before washing herself. •C. Give her a towel, washcloth and sop and take her to the shower area. •D. Ask her to wait to wash until after the physician examines her.

D collection of evidence