Ch 28 & 29 (Psych)

What are the indicators of sexual abuse recovery in a patient? Select all that apply.

Expressions of hope Feelings of empowerment Healing of physical injuries Evidence of comfort in relationships

A nurse is performing a clinical examination of a patient who was sexually abused. The nurse finds that the patient has reduced blood pressure, hypothermia, and respiratory depression. Which "date rape" drug would the nurse expect to find in the patient's blood sample report?

G-hydroxybutyric acid

What is the action of an emergency contraceptive pill?

It inhibits the process of ovulation.

A patient who was sexually assaulted was treated effectively and discharged. What appropriate action should the nurse follow while discharging the patient?

The nurse should give printed follow-up instructions to the patient.

The nurse is assessing an adolescent patient who has been raped by a stranger. What question should the nurse ask the patient to assess the likelihood of pregnancy?

"What is the date of your last menstrual period?"

Which principle will guide the nursing interview that is focused on identifying possible family-centered violence? Select all that apply.

Establishing a trustful rapport is the initial nursing intervention. Focus upon identifying problems and acceptable ways of solving them. Open-ended questions can be less threatening and elicit more relevant information.

A victim of domestic abuse is being treated for low self-esteem. What are the expected treatment outcomes? Select all that apply.

Maintains eye contact and erect posture Describes positive level of confidence Expects positive responses from others

What should a community health nurse include in the assessment of an older patient when elder abuse is suspected? Select all that apply.

Medication mismanagement Inadequate utilities and space Lack of access to basic necessities

Which statement is a myth concerning sexual assaults? Select all that apply.

Most women are raped by strangers. Most rapes occur for the purpose of sex. Sexual assaults are generally impulsive, unplanned acts. Fighting back will only result in additional physical injuries.

A nurse plans to give secondary prevention to a patient who was sexually abused. Which action by the nurse indicates effective nursing practice? Select all that apply.

The nurse treats the injuries of the patient. The nurse arranges a housekeeper for the patient's family.

Which assessment finding would the nurse expect in a patient who needs further treatment for post-traumatic stress disorder (PTSD)?

The patient is restless.

What is the priority outcome for a child who has been sexually abused?

The sexual abuse will cease

Nurses working in emergency departments and walk-in clinics should be aware that victims of violence may commonly present in which manner?

With vague physical complaints such as insomnia or pain.

The nurse is caring for a patient and suspects the patient is a victim of sexual abuse by a member of the family. The patient speaks and comprehends Spanish only. Which strategy should the nurse use while assessing the patient?

Work with a trained medical interpreter.

A patient who was raped one year ago talks with the nurse. Which comment by the patient indicates a successful resolution of this traumatic event?

"Although I have a nightmare once in a while, most of the time I sleep soundly."

It has been 6 months since a patient who was raped began counseling. Which statement by the patient would indicate that an important outcome has been met?

"I am not going to let that rapist be in control of my life. I know things will keep getting better."

A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate?

"I have seen rape victims from 6 months to 90 years old."

A nurse is caring for a patient who was sexually assaulted at a party. The nurse teaches cognitive coping skills to the patient. Which response by the patient indicates effective teaching by the nurse?

"It is now my turn to support my parents and take care of them."

A sexual assault victim tells the nurse, "I should have tried to fight him off! But I was so terrified that I could not move. I should have tried harder." What would be a supportive response from the nurse?

"The way you behaved was the right thing to do at the time."

When a woman reports an injury after being abused by her husband, the nurse listens to her attentively and asks her necessary questions to understand the history. What should the nurse do next to help this woman?

Assess safety and help explore alternatives to reduce dangers.

An adolescent brings a friend to the emergency department. The adolescent says to the triage nurse, "My friend was raped. Somebody gave her some Special K." The friend is confused, dazed, and drooling. What is the nurse's priority action?

Assess the friend's airway and breathing pattern.

Which is the most serious behavior for a woman attempting to escape a chronically abusive relationship to adapt?

Considering ways to commit suicide

When interviewing an adult victim of abuse, what is the nurse's best approach?

Direct and professional

Which is a common drug that is illegally used for victims of date rape and also used to treat narcolepsy?

Gamma-hydroxybutyric acid (GHB)

In the emergency department, a rape victim is examined and evidence is collected. How will this care be reimbursed?

Government or tribal resources pay for the care.

A patient who was physically abused is diagnosed with hopelessness related to social isolation, fear related to perceived physical threat, and risk of infection related to injuries. What outcomes indicate effective treatment?

Has effective wound healing

A woman reports being in an abusive relationship with her husband. What drives a man to act as a perpetrator in an abusive relationship? Select all that apply.

He feels more powerful when he uses force and abuse. He feels he is in charge and dominant in the relationship. He imposes restrictions due to extreme pathological jealousy.

Which information is considered a part of the general nursing assessment of a victim who has experienced a physical assault? Select all that apply.

Level of anxiety Coping mechanisms Indications of physical trauma Indications of emotional trauma

In the context of abuse assessment, on which areas should a nurse concentrate? Select all that apply.

Levels of anxiety and coping responses Observations of the family's patterns of coping Indications or patterns of violence in vulnerable families

Three weeks after being raped by an adult male, a petite college female says to the nurse, "My roommate says the rape was my fault. She says I could have gotten away if I had tried." What information will the nurse consider when responding to this comment? Select all that apply.

Most men can overpower most women because of differences in body build. Victims of rape often panic, resulting in decisions and actions that are ineffective.

Which statement is currently true regarding the existence of sexual assault in the United States? Select all that apply.

Nearly one in five women has been raped within her lifetime. Nearly a third of male victims were raped by intimate partners. The male is likely to have been victimized by several assailants.

The nurse is counseling a victim of family violence. What key idea does the nurse need to emphasize to the victim during crisis intervention?

People have a right to live without fear of violence, physical harm, or assault.

A nurse assesses a victim of intimate partner violence who says, "He's going to kill me next time if I don't do something." Which nursing diagnosis has the highest priority?

Powerlessness

A group of nursing students was given an assignment to assess the abuse victims in the gynecology ward using the abuse assessment screen. The students find that the majority of the patients got a score of 2. Which incident of abuse does this score indicate?

Slapping, pushing; no injuries or continuing pain

While assessing the blood glucose levels of a pregnant patient, the nurse suspects that the patient has been physically abused. What appropriate action should the nurse take to support and protect the patient? Select all that apply.

Suggest to the patient to be admitted to the hospital. Take a photograph of the patient's wounds as evidence. Listen effectively to the patient while conducting the interview.

An individual with substance abuse problems is more likely to behave as a perpetrator in family violence. How do alcohol and other drugs trigger this behavior in an individual?

The person develops a disregard for social rules.

A woman in the sixth month of pregnancy presents in the emergency department with complaints of a severe headache. Her partner answers the assessment questions, even though they are directed to the woman. The woman has a depressed affect and slumped shoulders. The nurse recognizes the need for further assessment related to which of the following?

The risk of intimate partner violence

The nurse is preparing a safety plan for a victim of family violence. How does a safety plan help the victim?

The victim can identify signs of occurrence of violence and leave.

Which statement demonstrates a risk for abusive parenting? Select all that apply.

"I can't remember ever being told I was loved." "Drinking a beer or two helps me to calm down." "It's been really hard since the divorce became final." "If the children would only listen to me things would be okay."

Which nursing intervention is most appropriate during the follow-up visit of a rape survivor after discharge from the hospital?

Assessing for pregnancy

A nurse visits an old age home to assess the presence of abuse. Which response of a patient would indicate that he or she has been neglected?

"I am unable to administer the medications; the medication bottles are not clearly marked."

Place the following forms of reported child abuse in order of frequency.

Neglect Physical abuse Sexual abuse Emotional abuse

The nurse is formulating a plan of care for a patient who is a victim of sexual abuse. What is a priority nursing diagnosis?

Risk for violence

The nurse is preparing to assess a patient who is in the emergency room accompanied by friends. The friends report that the patient may have been "roofied." What does the nurse immediately assess to check for symptoms of an overdose?

Airway

Which statements are true concerning rape? Select all that apply.

Rape is an expression of aggression and anger. Women do not "ask" to be raped by their behavior or dress Male victims are more likely to experience physical trauma and to have been victimized by several assailants.

In the cycle of violence, during which stage does the abuser apologize and promise the abuser that the abuse will never happen again?

Honeymoon

What is commonly the result of abuse in childhood? Select all that apply.

Running away The onset of clinical depression Posttraumatic stress disorder (PTSD)

Abuse comes in which forms? Select all that apply.

Sexual Physical Emotional Economic

Which factor is of least importance as a victim of spousal abuse constructs a safety plan?

How the victim will explain the decision to leave

A person is treated for a severe back injury resulting from domestic abuse. What is the key question that a nurse should ask to assess if the victim needs any further intervention?

If the patient has any desire to kill the perpetrator

The nurse is developing a plan of care for a person who is hostile, demonstrates poor coping skills, and is addicted to substances. What would be an appropriate nursing diagnosis for this person?

Ineffective individual coping

Which of the following would be an appropriate long-term outcome for a rape victim?

Integrate the rape event and resume an optimal level of functioning.

What distinction can be made between abuse and neglect?

Neglect is a failure to provide; abuse is a failure to control physical aggression.

A nurse prepares the case report of a patient who was sexually abused. What information does the nurse record in the patient's case report? Select all that apply.

Nightmares Feelings of guilt Excessive masturbation

Which intervention is appropriate when caring for a sexual assault victim who is being examined initially? Select all that apply.

Securing samples for legal evidence Providing detailed explanations concerning the procedures Obtaining consent for the rape protocol to be implemented Performing a physical assessment to identify bruises and lacerations

A woman seeks outpatient therapy 2 weeks after being raped. She complains of insomnia, decreased appetite, episodes of panic, and feeling vulnerable when she is away from home. What are the most appropriate nursing interventions for the plan of care? Select all that apply.

Teach the patient stress management techniques. Use active listening to validate the patient's feelings. Refer the patient to a support group for victims of rape. Continue to monitor this patient for depression, post-traumatic stress disorder, and suicidal thinking.

A mother brings her 4-year-old daughter to the emergency department and states that the child has been "acting funny." The mother states, "She touches her vagina and rubs herself down there all the time and she never did that before." This behavior best supports which conclusion?

The child has been sexually abused.

The nurse is physically assessing a 7-year-old who is suspected of being physically abused. Which observation supports this diagnosis?

The child has bruises in various stages of healing on his or her arms.

A school nurse assesses multiple bruises and welts in odd shapes on a child's back. Lately, this child has been frequently tardy and has had episodes of aggressive behavior in school. Identify the best initial outcome.

The child will form a trusting relationship with the nurse.

During a health screen in a boarding school, the nurse finds that the older children have been physically abused. Which signs and symptoms does the nurse find in the children?

The children hesitate to interact with the nurse.