Chapter 9

10. Which of the following assessment findings would lead the nurse to suspect that an 8-year-old child is the victim of sexual abuse? 1. The child is fearful of the caregiver and other adults. 2. The child has a lack of peer relationships. 3. The child has self-injurious behavior. 4. The child has interest in things of a sexual nature.

Hide Answer 10. The answer is 4. An 8-year-old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.

11. Which situation would the nurse identify as placing a client at high risk for caregiver abuse? 1. An adult child quits her job to move in and care for a parent with severe dementia. 2. An elderly man with severe heart disease resides in a personal care home and is visited frequently by his adult child. 3. An elderly parent with limited mobility lives alone and receives help from several adult children. 4. A wife cares for her husband who is in the early stages of Alzheimer's disease and has a network of available support persons.

Hide Answer 11. The answer is 1. In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parent. Caring for someone with severe dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse. The caregivers in option 2 are the staff working in the personal care home; the adult child does not have primary responsibility and, therefore, would not be at high risk for severe stress and abuse. In options 3 and 4, the caregivers are receiving support and no one person has primary responsibility. This will decrease the risk for severe caregiver stress.

12. While performing a prenatal assessment, the clinic nurse suspects that her client has been abused. Which of the following questions would be most appropriate? 1. Are you being threatened or hurt by your partner?" 2. "Are you frightened of your partner?" 3. "Is something bothering you?" 4. "What happens when you and your partner argue?"

Hide Answer 12. The answer is 1. The use of a simple, direct question, asked in an empathic manner, is best to validate the presence of an abusive situation. The other questions are indirect and may not lead to the discussion of an abusive situation.

13. Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply. 1. Enuresis 2. Red and swollen labia and rectum 3. Vaginal tears 4. Injuries in different stages of healing 5. Cigarette burns 6. Lice infestation

Hide Answer 13. The answer is 1, 2, 3. These are all indications that a female child has been the victim of sexual abuse. Options 4, 5, and 6 are signs of physical abuse of a child, not sexual abuse.

14. A client tells the community health nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. 1. Help the client to develop a plan to ensure safety, including phone numbers for emergency help. 2. Help the client to get her boyfriend into an appropriate treatment program. 3. Communicate acceptance, avoiding any implication that the client is at fault for not leaving. 4. Help the client to explore available options, including shelters and legal protection. 5. Tell the client that she should leave because things will not improve. 6. Reinforce concern for the client's safety and her right to be free of abuse.

Hide Answer 14. The answer is 1, 3, 4, 6. These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client's feeling responsible for the abuse. Advising the client to leave is inappropriate; the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.

2. A community nurse is making a home visit to a family of three: a mother, a father, and their child. The mother tells the nurse that the father (who is not present) has hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response by the nurse? 1. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening. 2. The nurse commends the mother's efforts and agrees to let her handle things. 3. The nurse commends the mother's efforts and also contacts protective services. 4. The nurse confronts the mother's failure to protect the child.

Hide Answer 2. The answer is 3. The nurse would validate and reinforce the mother's efforts to seek help; however, the nurse must also report the abuse to the appropriate protective services. The priority is to maintain the child's safety. The responses in options 1 and 2 are inappropriate; the nurse is failing to provide for the child's safety and is not following legal guidelines. In option 4, the nurse is alienating the mother, as well as failing to follow legal guidelines and ensure the child's safety.

3. During a well-child checkup, a mother tells the nurse about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. The nurse analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except: 1. conflictual relationships of parents. 2. inconsistent communication patterns. 3. rigid, authoritarian roles. 4. use of violence to establish control.

Hide Answer 3. The answer is 1. There is no evidence in this situation that the parents are in conflict; in fact, the mother is describing that the child "needed to be disciplined." Often, in dysfunctional families, one child is singled out to be the victim and is the recipient of blame for problems. The inconsistent communication pattern is that the child received conflicting messages regarding preparation of food. The rigid authoritarian roles demonstrated by the mother's indicate that the child needs discipline from the father. This is an example of a rigid role expectation of the father as disciplinarian. Also, the father used violence to retain the position of control.

4. Which of the following statements about family violence is true? 1. Family violence affects every socioeconomic level. 2. Family violence is caused by drug and alcohol abuse. 3. Family violence predominantly occurs in lower socioeconomic levels. 4. Family violence rarely occurs during pregnancy.

Hide Answer 4. The answer is 1. Family violence occurs in all socioeconomic levels, races, religions, and cultural groups. Although violence is associated with substance abuse, it is not the singular cause. The statement that family violence predominantly occurs in lower socioeconomic levels is false. Abuse often occurs during pregnancy; about 23% of all pregnant women seeking prenatal care are victims of abuse.

5. The nurse is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? 1. Flexible role functioning between parents 2. History of the parent having been abused as a child 3. Single-parent home situation 4. Presence of parental mental illness

Hide Answer 5. The answer is 2. One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy functioning, not abuse. Single-parent households and a history of mental illness are not established risk factors for child abuse by a parent.

6. A woman is admitted to the emergency department with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband, who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? 1. The wife's explanation is appropriate acceptance of her responsibility. 2. The wife's explanation is an atypical reaction of an abused woman. 3. The wife's explanation is evidence that the woman may be an abuser as well as a victim. 4. The wife's explanation is a typical response of a victim accepting blame for the abuser.

Hide Answer 6. The answer is 4. Self-blame is a common psychological response for a woman who is a victim of abuse. In this situation, the message that violence occurred because the woman provoked the abuser is accepted and owned by the victim; however, the victim is not responsible for the violence. The statements in options 2 and 3 are not true.

7. A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. The mother has three other children, the oldest of whom is age 12. The mother tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the younger children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation? 1. Delayed growth and development, related to performance expectations of child 2. Anxiety (moderate), related to difficulty managing home situation 3. Impaired parenting, related to role reversal of mother and child 4. Social isolation, related to lack of extended family assistance

Hide Answer 7. The answer is 3. The role of a 12-year-old child in a family should not be that of the parent. In this situation, the child and mother have reversed roles. There is no evidence that the child has delayed growth or development, the mother in this situation is not demonstrating signs of anxiety, and there is no evidence in this situation that the family is socially isolated.

8. What is the priority nursing intervention for a child or elder victim of abuse? 1. Assess the scope of the abuse problem. 2. Analyze family dynamics. 3. Implement measures to ensure the victim's safety. 4. Teach appropriate coping skills.

Hide Answer 8. The answer is 3. The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety. The question is asking about implementing a specific nursing action, not assessing the problem or analyzing the family dynamics. Teaching coping skills is important; however, the priority action involves ensuring safety.

9. A nurse working in the emergency department is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? 1. Contact the appropriate legal services. 2. Ensure privacy for interviewing the victim away from the abuser. 3. Establish a rapport with the victim and the abuser. 4. Request the presence of a security guard.

Hide Answer 9. The answer is 2. Privacy, away from the abuser, is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser (especially if she decides to return to the abusive situation). In this situation, it is not the nurse's responsibility to contact legal services; it is up to the woman to make the decision to report the abuse. However, whenever injury is inflicted with a gun, knife, or other weapon, the nurse is obligated to report the abuse. Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish rapport with the abuser. The situation does not describe the abuser as currently violent or under the influence of substances; therefore, requesting a security presence is inappropriate at this time.

9 Physical Abuse, Sexual Abuse, and Family Violence Study questions 1. An 11-year-old child complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like a new injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? 1. Contact the child's parents and ask about the child's injury. 2. Encourage the child to be truthful with her. 3. Question the teacher about the parent's behavior. 4. Report suspicion of abuse to the proper authorities.

Hide Answer The answer is 4. The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse. The parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency. Although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate. Questioning the teacher may or may not provide validation of the nurse's suspicions; regardless, this intervention does not ensure the child's safety, which is the priority.