Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders, Chapter 27 Anger, Aggression, and Violence, VARCAROLIS Chapter 28: Child, Older Adult, and Intimate Partner Violence, VARCAROLIS...

MULTIPLE CHOICE 1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543 | Page 546 TOP: Nursing Process: Implementation

Client Needs: Safe, Effective Care Environment 17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Safe, Effective Care Environment 19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 541-542 | Page 547-548 TOP: Nursing Process: Evaluation

Client Needs: Psychosocial Integrity 12. A nurse works a rape telephone hotline. Communication with potential victims should focus on: a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.

A 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. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 555-556 | Page 559 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 16. A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction c. A delayed reaction b. The long-term phase d. The angry stage

A The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 554-555 | Page 558 (Table 29-2) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment MULTIPLE RESPONSE 1. A 10-year-old 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 as priorities to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

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 would not be a priority at this time. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 544-545 | Page 548 (Nursing Care Plan 28-1) TOP: Nursing Process: Planning

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

A, B, D Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patients presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

Select all that apply. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? a. Appoint a person to clear a path and open, close, or lock doors. c. Select the person who will communicate with the patient. e. Remove jewelry, glasses, and harmful items.

ANS: A, C, E Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Select all that apply. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? a. Stating the expectation that the patient will stay in control d. Offering to provide the patient with medication to help e. Speaking in a firm but calm voice

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

Select all that apply. Which central nervous system structures are most associated with anger and aggression? a. Amygdala d. Temporal lobe e. Prefrontal cortex

ANS: A, D, E The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? b. Notify the health care provider to obtain a seclusion order.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. b. Help the patient identify incidents that trigger impulsive anger.

ANS: B Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting out anger, and eventually to put into practice more adaptive coping strategies.

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? b. "My fingers are tingly."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? b. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia.

ANS: B Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient's anxiety and anger. Dependency is not an important concern related to acute pain.

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? c. Olanzapine (Zyprexa)

ANS: C Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

Which scenario predicts the highest risk for directing violent behavior toward others? c. Paranoid delusions of being followed by alien monsters

ANS: C Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: c. a personality style that externalizes problems.

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

n emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? c. Periodically provide an update and progress report on the patient.

ANS: C Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse's feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by: c. saying to the patient, "This is a safe place."

ANS: C Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient's attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient's attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? c. A wish for revenge

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: c. "You want to go home to prepare your husband's dinner?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient's feelings.

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? d. The patient interpreted the UAP's behavior as potentially harmful.

ANS: D Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? d. Risk for other-directed violence

ANS: D Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is: d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient: d. presented a clear and present danger to others.

ANS: D The patient's threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

Client Needs: Psychosocial Integrity 17. A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should: a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.

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 later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 558 (Box 29-1) | Page 561 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 18. An unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party. Priority action by the nurse should focus on: a. preserving rape evidence. b. maintaining physiologic stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.

B Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiologic stability. The distracters are of lower priority than preserving physiological functioning. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 556-558 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 11. A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"

B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a non-therapeutic communication technique. The victim may or may not have friends who have had this experience, but it's important to talk about his feelings rather than theirs. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 553-554 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding 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

B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 (Table 28-3) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 16. An older adult with Alzheimer's disease lives with family in a rural area. 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. Multiple caregivers c. Living in a rural area b. Alzheimer's disease d. Being part of a busy family

B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534-535 TOP: Nursing Process: Assessment

Client Needs: Physiological Integrity 14. Which situation describes consensual sex rather than rape? a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.

B Only the key describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are of legal age. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 553 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

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 feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 TOP: Nursing Process: Planning

Client Needs: Safe, Effective Care Environment 14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 539 | Page 541-542 TOP: Nursing Process: Outcomes Identification

Client Needs: Safe, Effective Care Environment 18. An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my 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 about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

B The patient's caregivers 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 546-547 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group c. A women's shelter b. A mental health center d. Vocational counseling

C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537 | Page 544 (Box 28-6) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 10. A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."

C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 562 TOP: Nursing Process: Evaluation

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

C, D, E PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individuals extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

Client Needs: Safe, Effective Care Environment 10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. c. Call the adult protective agency. b. Arrange for hospitalization. d. Document injuries with a body map.

D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would 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. Admission to the hospital is not necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 540-541 | Page 548-549 (Nursing Care Plan 28-1) TOP: Nursing Process: Implementation

Chapter 29: Sexual Assault MULTIPLE CHOICE 1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 553-554 | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 15. Before a victim of sexual assault is discharged from the emergency department, the nurse should: a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.

D Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556 | Page 558 (Box 29-1) | Page 561 TOP: Nursing Process: Implementation

Client Needs: Safe, Effective Care Environment 13. A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol) by an assailant. Which intervention has priority? Monitoring for: a. coma. c. hypotonia. b. seizures. d. respiratory depression.

D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 554 (Table 29-1) TOP: Nursing Process: Intervention

The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

c. depression. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

c. hippocampus. The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents: a. visit their child's grave daily. b. maintain their child's room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

d. throw flowers on the lake at each anniversary date of the accident. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

Client Needs: Physiological Integrity 7. A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-557,559-560 TOP: Nursing Process: Implementation

Client Needs: Safe, Effective Care Environment 11. A patient tells the nurse, "My husband lost his job. He's 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 c. Abuse of alcohol b. Loss of employment d. Poverty

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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 13. After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Psychosocial Integrity 5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused. c. have eating disorders. b. are attention seeking. d. are developmentally delayed.

A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 533 (Box 28-1) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 8. An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." 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

A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 28û22 | Page 23 | Page 51 (Box 28-4) TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Physiological Integrity 19. A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."

A The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 555 | Page 557 TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest 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 an interview with these parents? Select all that apply. a. "Tell me how you discipline 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 spank your children?" e. "Calling children 'stupid' injures their self-esteem."

A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 535-537 (Box 28-3) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 3. An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply. a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer

A, B, C Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 555-556 | Page 557-558 (Box 29-1) | Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 2. A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.

A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 555-556 | Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

A, B, C, E The childs symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the childs distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security

The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

A, B, C, E, F These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, 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

A, C, D These reactions are common to the long-term 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 would not be expected. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 560-561 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation

Client Needs: Safe, Effective Care Environment 2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone 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. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

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. 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543-544 (Box 28-6) TOP: Nursing Process: Planning

Client Needs: Safe, Effective Care Environment 4. Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? Select all that apply. a. Coping mechanisms the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

A, D, E The nurse assesses the victim's level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-558 TOP: Nursing Process: Assessment

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient's right and may be appropriate. The other incorrect options do not feature violation of another's rights.

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

ANS: A Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork

ANS: A Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the day room. While following the patient into the day room, the nurse should: a. make sure there is adequate physical space between the nurse and patient.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

Select all that apply. Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? a. Patient behaviors associated with the incident c. Intervention techniques used by the staff d. Effects of environmental factors

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.

Which assessment finding presents the greatest risk for violent behavior directed at others? b. History of spousal abuse

ANS: B A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room: b. accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

ANS: B A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? c. Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected."

ANS: C Anger is cognitively driven. The answer helps the patient test his cognitions and may lead to lowering his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: c. "I'd like to talk with you about how you're feeling right now."

ANS: C Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient's ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient's feelings and concerns. This leads to the next step of planning an intervention.

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of: d. substance abuse.

ANS: D The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

Client Needs: Psychosocial Integrity 5. An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects

B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 557-558 (Box 29-1) | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 3. After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity c. Flashbacks and dreams b. Confusion and disbelief d. Fears and phobias

B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 554 | Page 558 (Table 29-2) | Page 560 (Nursing Care Plan 29-1) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 6. A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

B Salty water is a slang/street name for GHB (γ-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 554 (Table 29-1) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 5. A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should: (select all that apply) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.

B, D As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 557-558 (Box 29-1) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 6. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 543 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 2. An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual c. Emotional b. Physical d. Economic

C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 538-539 TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain. c. bruises on extremities. b. repeated middle ear infections. d. diarrhea.

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, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological c. Physical b. Financial d. Sexual

C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 537 (Box 28-4) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 12. An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building c. Honeymoon b. Acute battering d. Stabilization

C The honeymoon stage is characterized by kind, 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 stabilization stage. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 8. A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."

D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556-557,559-560 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 2. A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak c. Moderate b. Mild d. Severe

D Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 560 (Nursing Care Plan 29-1) + learning from Chapter 15 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 9. The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 556 | Page 558 | Page 561 TOP: Nursing Process: Planning/Outcomes Identification

Client Needs: Psychosocial Integrity 9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships c. Socialization skills b. Work responsibilities d. Physical injuries

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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy? a. Compensation c. Projection b. Somatization d. Denial

D The patient's statements reflect use of denial, an ego defense mechanism. This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape. The patient's statements do not reflect somatization, compensation, or projection. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 558 (Table 29 - 2) + learning from Chapter 15 TOP: Nursing Process: Assessment

Which assessment finding best supports dissociative fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

a. "I cannot recall why I'm living in this town." The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. See relationship to audience response question.

Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are lost to the patient (blackouts). See relationship to audience response question.

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

a. Reexperiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

a. engage the parasympathetic nervous system. In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

a. risk for self-harm. Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

After the sudden death of his wife, a man says, "I can't live without her...she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

b. "Her death is a terrible loss for you." Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

b. "Use short, simple sentences and keep the environment calm and protective." Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patients time should not be loaded with demanding or stimulating activities.

A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

b. Engage the patient in a physical activity such as exercise. Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

b. Explain that the physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the bodys responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

b. Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

c. Anger is an expected emotion in an adjustment disorder. Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

A soldier who served in a combat zone returned to the U.S. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

c. Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

c. Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

c. Sympathetic nervous system The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

d. Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school.

d. create a scholarship fund at their child's high school. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.