Ch 20-22

A patient tells the nurse, "My husband is abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive

Which premise is most useful to a nurse planning crisis intervention for any patient? a. The patient is experiencing a state of disequilibrium. b. The patient is experiencing a type of mental illness. c. The patient poses a threat of violence to others. d. The patient has a high potential for self-injury.

ANS: A Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Disgust b. Concern c. Empathy d. Compassion

ANS: A Feelings of empathy, concern, and compassion are helpful. Disguise, on the other hand, may make objectivity impossible and can increase the child's anxiety and shame.

A victim of intimate partner violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on what? a. Supporting emotional security and re-establishing equilibrium b. Offering long-term resolution of issues precipitating the crisis c. Promoting growth of the individual d. Providing legal assistance

ANS: A Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and re-establishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Depressive symptoms

ANS: A The diagnosis of a concussion suggests violence as a possible cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for intimate partner violence.

An adult has cared for a debilitated parent for 10 years. The parent's condition recently declined, and the health care provider recommended placement in a skilled care facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to what? a. Resolving the feelings associated with the threat to the person's self-concept b. Maintaining the ability to identify situational supports in the community c. Relying on the assistance from role models within the person's culture d. Mobilizing automatic relief behaviors by the person

ANS: A The patient's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution involves coming to terms with the feelings associated with this loss. Identifying situational supports is relevant but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust. It is premature to focus of avoidance strategies now. The remaining options do not promote acceptance.

An older adult, diagnosed with Alzheimer's disease, lives with family and has multiple bruises. The home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to cognitive impairment and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at nigh

ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of impaired verbal communication or noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis risk for injury is a higher priority.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? (Select all that apply.) a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by "yes" or "no."

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? (Select all that apply.) a. Parental sessions to teach child-rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Foster placement of the children in foster care

ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? (Select all that apply.) a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient's privacy may be compromised by the presence of family. The rape victim's anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse

When an emergency department nurse teaches a victim of rape about reactions that may occur during the long-term organization (delayed) phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, D These reactions are common to the long-term organization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? (Select all that apply.) a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? (Select all that apply.) a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

ANS: A, D, E Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

ANS: B A child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment

ANS: B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

A nurse assesses an adult experiencing a crisis. What question asked by the nurse will best determine situational support? a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

ANS: B Only the correct answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. What is the nurse's best initial statement to this patient? a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I am going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

ANS: B A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety. The incorrect responses use nontherapeutic techniques, including false reassurance and giving advice.

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should provide what support? a. Assure the patient, "Before you leave you receive prophylactic treatment for sexually transmitted infections (STIs)." b. Provide written information concerning the physical and emotional reactions that may be experienced. c. Explain the need and importance of human immunodeficiency virus (HIV) testing in this situation. d. Offer both verbal and written information about locally available legal resources.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Presenting legal information is not an appropriate nursing intervention. Treatment for sexually transmitted infections is important but at this point it is premature to do so without sufficient assessment and testing.

When a victim of sexual assault is discharged from the emergency department, the nurse should arrange for which intervention? a. Secure support from the victim's family. b. Provide referral information verbally and in writing. c. Advise the victim to try not to think about the assault. d. Offer to stay with the victim until stability is regained.

ANS: B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

ANS: B Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." How should the nurse respond to the request? a. Arrange for the patient to shower. b. Explain that washing would destroy evidence. c. Give the patient a basin of hot water and towels. d. Instruct the victim to wash above the waist only.

ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

ANS: B Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression b. Teaching stress-reduction techniques to a beginning student nurse c. Assessing coping strategies used by a patient who has attempted suicide d. Referring a patient with schizophrenia to a partial hospitalization program

ANS: B Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. "She was very beautiful." b. "She wanted the sex." c. "I have issues with my mother." d. "I've been depressed for a long time."

ANS: B Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining (protective) order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

ANS: B The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining (protective) order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

ANS: B The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not shown to be altered at this point.

An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

ANS: B The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. None of the other options proves the necessary level of safety.

An older adult diagnosed with dementia lives with family and attends an adult day care center. A nurse at the center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: C The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

When working with rape victims, what is the focus of initial care? a. Collecting forensic evidence b. Notifying law enforcement c. Helping the victim feel safe d. Documenting the victim's comments

ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.

An adult tells the nurse, "I can't take anymore! My mother passed away, my husband lost his job and yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending breast surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

ANS: C This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of deficient knowledge, fear, or impaired verbal communication.

A woman says, "I can't take anymore! Last year my husband had an affair. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

ANS: C A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

. An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

ANS: C Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? a. Repeated middle ear infections b. Severe colic c. Bite marks d. Croup

ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

ANS: C Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

ANS: C Obtaining the person's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

Which agency provides coordination in the event of a terrorist attack? a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

ANS: C The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is how long in weeks? a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

ANS: C The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis

An adult tells the nurse, "My partner abuses me only when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency

ANS: C The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient's need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to inflect violence or control others

ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and violence. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

A woman says, "I can't take anymore! Last year my husband was diagnosed with cancer. Three months ago, I lost my job. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the divorce d. Coping with the reaction to the daughter's events

ANS: D The focus of crisis intervention is on the most recent problem—"the straw that broke the camel's back." The patient has coped with the breast lesion, the divorce, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

A nurse working a rape telephone hotline should focus communication with callers toward what intervention? a. Arranging long-term counseling b. Serving as a sympathetic listener c. Obtaining information to relay to the local police d. Explaining immediate steps that a victim of rape should take

ANS: D The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the monster that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority question? a. "What do you mean when you say 'monster'?" b. "What resources do you need to help you cope with this situation?" c. "Would you consider hurting yourself or the person on trial?" d. "Are you having thoughts of hurting yourself or others?"

ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options may be important but not the highest priority.

A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started feeling this way?"

ANS: D A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking "why" questions are a nontherapeutic communication technique.

Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy. b. Case manager whose patients are seriously mentally ill and are being cared for at home. c. Health care employee who worked 8 hours at the information desk of an intensive care unit. d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store.

ANS: D Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to victims of trauma.

A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: D Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.

An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the employee says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Notify the police. b. Refer the employee to a shelter. c. Notify the adult protective agency. d. Document injuries with a body map.

ANS: D Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. A shelter may be suggested later, but it is not the next action.

After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as what? a. Marginally satisfied b. Somewhat satisfied c. Moderately satisfied d. Very satisfied

ANS: D The patient mentions a number of indicators that suggest a high degree of satisfaction with psychological care received. No indicators express low-to-moderate satisfaction.

Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55 year old d. A riot at a rock concert

ANS: D The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (Select all that apply.) a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

B, C, F

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. What is the priority action they staff members should focus on? a. Maintaining effective gas exchange b. Preserving all rape evidence c. Interviewing the friend for additional information d. Determining whether any alcohol of drug were ingested

ANS: A Because the patient is unconscious, the risk for respiratory depression and airway obstruction is present; therefore, the nurse's priority focus is to maintain gas exchange. The incorrect options are of lower priority than preserving physiological functioning.

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not an indicative of any particular phase.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. The patient attends anger management classes. Which finding indicates success in this plan of care? a. The patient expresses frustration verbally instead of physically. b. The patient explains the rationale for behaviors to the victim. c. The patient identifies three personal strengths. d. The patient agrees to seek counseling.

ANS: A The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

Which patient statement best suggests they have returned to a pre-crisis level of functioning? a. "My boss told me I am doing well and up for a promotion." b. "I understand that bad things can happen to really good people." c. "Going to my support group regularly has made a big difference." d. "I'm much more comfortable asking for help than before my divorce."

ANS: A Resolution of a crisis can result in a return to pre-crisis functioning, or a higher or lower level of functioning. The goal of crisis intervention is a return to at least pre-crisis functioning level. A good job performance evaluation is suggestive of pre-crisis functioning." The other options suggest that the patient is working toward that goal.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

ANS: A The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

ANS: A The victim's words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

After treatment for a detached retina, a victim of intimate partner violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

ANS: B Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

A survivor in the long-term organization (delayed) phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? a. The survivor expresses a need to regularly withdraw from social situations. b. The survivor describes personal coping strategies for fearful situations. c. The survivor uses increased activity to reduce feelings of fear. d. The survivor expresses a deep desire to be with others.

ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

When responding to a natural disaster, after rescue and evacuation efforts are completed, what intervention will be the focus of the triage process? a. Planning the physical rebuilding of the community b. Coordinating food and shelter services c. Arranging for temporary schools d. Debriefing first responders

ANS: B The first needs during a disaster include rescue and evacuation efforts, food and shelter, medical attention, and physical safety. While important all the other options are addressed after immediate needs are addressed

A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is experiencing what? a. Suicidal ideations b. Anxiety and fear c. Misperceived reality d. Homicidal ideations

ANS: B Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed. None of the other options are supported with behaviors.

A woman says, "I can't take anymore, and I have no children or husband to turn too! This last year has been on crisis after another." If this person's immediate family is unable to provide sufficient situational support, what should the nurse do? a. Suggest hospitalization for a short period. b. Ask what other relatives or friends are available for support. c. Tell the patient, "You must be strong. Don't let this crisis overwhelm you." d. Foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of situational supports should continue. Although the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

A nurse works with a person who was raped 4 years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

ANS: B A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

ANS: B An adventitious crisis is a crisis of disaster that is not a part of everyday life; it is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. Organic is not a type of crisis.

A clinic nurse interviews an adult patient accompanied by a partner who reports fatigue, back pain, headaches, tension, and sleep disturbances. The patient then becomes reluctant to provide more information and wants to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the partner leave the patient alone to continue the assessment. c. Ask whether the patient has ever had psychiatric counseling in the past. d. Ask the patient to disrobe so that assessment for signs of physical abuse can occur.

ANS: B In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to speak more candidly if the partner is not in the room. None of the other options focus on the client's reluctance to continue the assessment process.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to under involvement with the victim. d. Positive feelings promote the development of sympathy for patients.

ANS: B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better.

ANS: B The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she "cannot think clearly."

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

ANS: B The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.

Which activities are in the scope of practice of a sexual assault nurse examiner (SANE)? (Select all that apply.) a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within the practice role of this specially trained nurse.

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

ANS: C A reflective communication technique is helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim's perceived role and interfere with further discussion.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety? a. Minimal b. Mild c. Moderate d. High

ANS: D Anxiety is the result of a personal threat to the victim's safety and security. In this case, the person's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Minimal" is not a level of anxiety. Mild and moderate levels of anxiety allow the person to function at a higher level.

A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

ANS: D Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by "I can't take it anymore!"

ANS: D During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help

A nurse cares for a rape victim who was given flunitrazepam by the assailant. For which condition has priority? a. Decreased consciousness b. Seizure activity of any kind c. Hypotonia of voluntary muscles d. Signs and symptoms of respiratory depression

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

An older adult diagnosed with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

ANS: A Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder c. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent and an adolescent son who has just begun dating girls

ANS: A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

----

next

-----

next