Exam 2 (Mental Health)

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? (Select all that apply.)

- Conveying empathy and acknowledging the child's distress - Explaining and reinforcing reality to distortions - Using a calm manner and low, comforting voice - Staying with the child until the anxiety decreases

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:

- Create a scholarship fund at their child's high school

Which statement concerning syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered true?

- Culture-bound syndromes that are not dissociative disorders

A client undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the client smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the client using?

- Denial

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?

- Depersonalization disorder

A solider returns to the United States from active duty in a combat zone. The solider is diagnosed with PTSD. The nurse's highest priority is to screen the soldier for:

- Depression

What information should the nurse give to the family of a client who has had a dissociative episode?

- Dissociation is a method for coping with severe stress

Which of the following statements about dissociative disorders is true?

- Dissociative symptoms are not under the person's conscious control

A client performs ritualistic hand washing. Which action should the nurse implement to help the client develop more effective coping?

- Encourage the client to participate in social activities

Relaxation techniques help patients who have experienced major traumas because they:

- Engage the parasympathetic nervous system

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?

- Engage the patient in physical activity such as exercise

Which patient is at increased risk for the development of anxiety and will require frequent assessment by the nurse? (Select all that apply.)

- Exacerbation of asthma signs and symptoms - History of chronic obstructive pulmonary disease - Current treatment for unstable angina pectoris - History of a traumatic brain injury

A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?

- Explain that the physical symptoms are related to the psychological state

A student says, "Before taking a test, I feel very alert and a little restless." Which nursing intervention is most appropriate to assist the student?

- Explain that the symptoms result from mild anxiety and discuss the helpful aspects

A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier?

- Fireworks display on July 4th

A soldier returned to the United States from active duty in a combat zone. The solider was diagnosed with 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?

- Flashbacks

The gas pedal on a person's car became stuck on a busy interstate highway, causing the care to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect?

- Flashbacks

Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD? (Select all that apply.)

- Flashbacks of the accident - Hypervigilance - Irritability - Mania

Which medication should the nurse be prepared to educate patients on when they are prescribed a selective serotonin reuptake inhibitor (SSRI) for panic attacks?

- Fluoxetine (Prozac)

The symptoms of an adjustment disorder can include what characteristics? (Select all that apply.)

- Guilt - Social withdrawal - Anger - Depression

The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)

- Ineffective home maintenance - Chronic low self-esteem - Risk for injury

Empathic listening is therapeutic because it focuses on what action?

- Lessening feelings of isolation

Samantha is a new patient at the mental health clinic and is seeking assistance for what she describes as "severe anxiety". In addition to daily self-medicating with alcohol, Samantha describes long-term use of herbal kava. The nurse practitioner knows that kava is associated with inhibiting P450 and orders which of the following tests?

- Liver enzymes

A client experiences a sudden episode of severe anxiety. Of these medications in the client's medical record, which is most appropriate to give as a prn anxiolytic?

- Lorazepam

A nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first?

- Lower the client's current anxiety

You are caring for Susannah, a 29-year-old who has been diagnosed with dissociative identity disorder. She was recently hospitalized after coming to the emergency department with deep cuts on her arms with no memory of how this occurred. The priority nursing intervention for Susannah is:

- Maintain 1:1 observation

A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly use what term to document the student's experience?

- Mild anxiety

A client with an abdominal mass is scheduled for a biopsy. The client has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110/ What is the client's level of anxiety?

- Moderate

Nick, a construction worker, is on duty when a nearby completed wall suddenly falls, crushing a number of his coworkers. Although badly shaken initially, he seemed to be coping well. After 2 weeks after the tragedy, he begins to experience tremors, nightmares, and periods during which he feels numb or detached from his environment. He finds himself frequently thinking about the tragedy and feeling guilty that he was spared while many others died. Which statement about this situation is most accurate?

- Nick has an acute stress disorder and will benefit from anti-anxiety medications

A client diagnosed with obsessive-compulsive disorder has the nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?

- Persistent thoughts about bacteria, germs, and dirt

A 4-year-old is referred to the outpatient mental health clinic after being in a severe care accident during which the child's mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, "It's my fault because I'm bad." What trauma induced disorder does this data support?

- Posttraumatic stress disorder (PTSD)

A client preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?

- Present the information again in a calm manner using simple language

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident?

- Projection

For a client experiencing panic, which nursing intervention should be implemented first?

- Provide calm, brief, directive communication

A client fearfully runs from chair to chair crying, "They're coming! They're coming!" The client does not follow staff's directions or respond to verbal interventions. What is the initial nursing intervention of highest priority?

- Providing for the client's safety

A client tells a nurse, "My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had." This client is demonstrating:

- Rationalization

An individual experiences sexual dysfunction and blames it on a partner calling the person unattractive and unromantic. Which defense mechanism is evident?

- Rationalization

A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating which defense mechanism?

- Reaction formation

Dissociative identity disorder is characterized by what event?

- Recurring feelings of detachment from one's body or mental processes

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 PTSD is the soldier describing?

- Reexperiencing

A child who is able to regain mental stability after a traumatic event is said to be demonstrating what trait?

- Resilience

A client fearfully runs from chair to chair crying, "They're coming! They're coming!" The client does not follow staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?

- Risk for injury

The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is:

- Risk for self-harm

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.

- Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes."

A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety?

- Severe

A person runs fro 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?

- Sympathetic nervous system

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I can't bring myself to leave my apartment alone." Which nursing intervention is appropriate?

- Teach the person to use positive-talk techniques

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. Which response provides to best address the parent's concerns?

- The imaginary friend is a coping mechanism the child is using

In a parent-teacher conference, the school nurse meets with the parents of a profoundly shy 8-year-old girl. The parents hold hands, speak softly, respond briefly, and have poor eye contact. The nurse recognizes that the child is most likely exposed to parental modeling and:

- The inherited shyness trait

To maximize the therapeutic effect, which lifestyle practice should the nurse discourage for a patient who has recently been prescribed an antianxiety medication?

- Buying a large coffee with sugar and extra cream each morning on the way to work

A nurse plans health teaching for a client diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.)

- Caution in use of machinery - The importance of caffeine restriction - Avoidance of alcohol and other sedatives

Select the correct etiology to complete the nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to:

- Cognitive distortions associated with unresolved childhood abuse issues

A client checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and client explore the likelihood of an actual fire. The client states this event is not likely. This counseling demonstrates what appropriate principle of therapy?

- Cognitive restructuring

Ashley is a 21-year-old college student who was sexually assaulted at a party. She was seen in the local emergency department and referred for counseling after being diagnosed by the provider on call as having acute stress disorder. Which of the following treatment modalities would you expect to see used in therapy with Ashley?

- Cognitive-behavioral therapy

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of what defense mechanism?

- Compensation

A client is experiencing moderate anxiety. The nurse encourages the client to talk about feelings and concerns. What is the rationale for this intervention?

- Concerns stated aloud become less overwhelming and help problem solving begin

Which assessment finding best supports dissociative fugue?

- "I cannot recall why I'm living in this town."

Whose model does a nurse follow while conducting crisis intervention for a patient with acute stress disorder?

- Albert R. Roberts

The expected outcome at the conclusion of crisis intervention therapy is that the patient will function in which of the following ways?

- At the pre-crisis level

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?

- Consent signed by the patient

Abuse comes in which forms? (Select all that apply.)

- Economic - Emotional - Physical - Sexual

What is the most appropriate statement about the victims of abuse?

- Females face intimate partner abuse more often than males

An elderly client pays the bills because she fears that her family will make her live elsewhere if she doesn't "help out". The nurse assesses it as:

- Financial maltreatment

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child?

- Hypervigilance

When the patient begins to sob uncontrollably and speech becomes so incoherent that the patient is unable to give the nurse any information, immediate interventions will focus on:

- Lowering the patient's anxiety level from severe to moderate

Crises that occur as an individual moves from one developmental level to another are called:

- Maturational crises

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:

- Respiratory depression

When a person becomes unemployed, he or she is likely to experience a(n):

- Situational crisis

A client experiencing panic suddenly began running and shouting, "I'm going to explode!" What is the nurse's best action?

- Tell the client, "Stop running and take a deep breath. I will help you."

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.

- The patient agrees to a follow-up appointment with a rape victim advocate

The nurse working with a client in crisis must initially assess for the client's:

- Unrealistic report of a crisis-precipitating event

An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response?

- "Are you having thoughts of hurting yourself or others?"

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.

- "Are you thinking about harming yourself?"

A nurse assesses a client with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?

- "Do you find it difficult to control your worrying?"

Considering the guilt that women feel after being sexually assaulted, which nursing assessment question has priority?

- "Do you have any thoughts about harming yourself?"

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 the victim's friend?

- "Has the victim consumed any alcohol?"

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

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

Which patient statement indicates the helpfulness of the nurse-patient relationship?

- "I appreciate the time you spent with me. I have a better understanding of what I can do to manage my problem."

You are assessing Lindy, a 25-year-old woman who came into the emergency department with a broken arm. She states she slipped on the ice of the steps outside her home. She has numerous bruises in different stages of healing. Her boyfriend, with whom she lives, accompanied her to the emergency department and aggressively responds to questions posed for the patient, while the patient remains silent. What is your best response to the boyfriend?

- "I now need to examine Lindy in private. Please wait outside the room. I will come get you when we are finished."

Which statement would suggest to the crisis intervention nurse the need to arrange for hospitalization of a client?

- "I see no solution for this situation and if nothing changes by tomorrow..."

A patient comes to the crisis clinic after an unexpected job termination. The patient paces around the room sobbing, cringes when approached, and responds to questions only with shrugs or monosyllables. Choose the nurse's best initial comment to this patient.

- "I see you are feeling upset. I'm going to stay and talk with you to help you feel better."

Which statement made by a new mother should be explored further by the nurse?

- "I think the baby cries just to make me angry."

Maggie, a child in protective custody, is found to have an imaginary friend, Holly. The foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:

- "I understand that imaginary friends are a coping mechanism."

You are working at a telephone hotline center when Abby, a rape victim calls. Abby states she if afraid to go to the hospital. What is your best response?

- "I'm here to listen, and we can talk about your feelings."

A rape victim visited a rape crisis counseling weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful?

- "I'm sleeping better although I still have an occasional nightmare."

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills?

- "In the past, how have you handled difficult or stressful situations?"

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?

- "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person."

Which statement made by a parent of a child with Tourette's syndrome would be assessed as a risk factor for family violence?

- "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs."

A 79-year-old patient in the emergency department is 5'6'', weighs 93 pounds, and is wearing old, dirty clothes that have holes. The patient is diagnosed with pneumonia. Which comment by this patient suggests a significant risk for abuse?

- "Our family is so poor, so my daughter gets my monthly retirement and Social Security checks."

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.

- "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

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 outside alone at night, I'll be safe from sexual attacks." Choose the nurse's best response.

- "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse?

- "So if you dress conservatively, your risk of being raped is small."

Which statement, made by the client diagnosed with dissociative identity disorder, demonstrates effective understanding to the question, "What exactly are the 'alters' your provider told you about?" illustrates that the education you provided has been effective?

- "So, alters are separate personalities with their own characteristics that take over during stress."

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.)

- "Tell me how you discipline your children." - "How do you stop your baby from crying?" - "Caring for four small children must be difficult."

The nurse is counseling a patient at a crisis center. After assessing the patient's situation, the nurse identifies that the patient is suffering from adventitious crisis. Which patient response supports the nurse's findings?

- "Terrorists brutally killed all the passengers; I somehow managed to escape."

A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates the use of this defense mechanism?

- "That person should not have provoked me."

Which statement made by a sexually assaulted patient strongly suggests the drug gamma-hydroxybutyric acid (GHB) was involved in the attack?

- "The drink I was given had a salty taste to it."

When discussing the symptoms of post-traumatic stress disorder (PTSD), the nurse should make which statement?

- "The symptoms can occur almost immediately or can take years to manifest."

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

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

Three weeks after a client was raped, she tells the nurse, "I am going crazy. I have nightmares and wake up screaming. Then during the day all sorts of thoughts about the rape intrude into whatever I am concentrating on. I can't get anything done at work." The nurse should reply:

- "These are a normal response to stress and will decrease with time and therapy."

A woman comes to the crisis intervention clinic and reports that her 16-year-old son uses frugs in the home and often assaults her. The nurse tells the client,:

- "Together we will be able to work on this problem."

A nurse delivered a lecture at a community health center on interventions to reduce family abuse. The nurse asks the participants what they learned from the session. Which statement given by the participants indicates effective learning?

- "Victims are not believed when they disclose their situatoin."

A major hurricane destroyed a community. Afterward, which best comment best predicts that a victim will be able to maintain or properly return to a state of equilibrium?

- "We had had big storms before. If we pull together, we can help each other and rebuild our community."

Which comment by the parents of a young child best demonstrates support of development of resilience and effective stress management?

- "We spend daily family time talking about experiences and feelings."

To assess the patient's perception of the event precipitating the crisis, the nurse would initially ask:

- "What was happening just before you began to feel this way?"

A patient being seen in the clinic for superficial cuts on both wrists is pacing and sobbing. After a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking:

- "What was happening just before you started to feel this way?"

A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support.

- "Who can be helpful to you during this time?"

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse?

- "You are feeling violated because you thought you could trust your partner."

During the immediate post-rape period, what verbal nursing intervention would best lower the client's anxiety and increase feelings of safety?

- "You are safe here. I will stay with you while you have your examination."

You are working in the emergency department caring for 21-year-old Larissa, who has just been raped. Which is your best initial response?

- "You are safe here."

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response.

- "You feel as though this would not have happened if you had not been alone."

A nurse is depressed after being unsuccessful in managing a patient in crisis. While reviewing the nurse's care plan, a nurse manager finds that the nurse had set unrealistic goals for the patient. What suggestion does the nurse manager give to the nurse?

- "You should stop setting goals and encourage the patient to set self goals."

A crisis is so acutely uncomfortable to the individual that it is likely to self-resolve in what time frame?

- 4 to 6 weeks

A patient who is visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is:

- 4 to 8 weeks

Which child is at lowest risk for abuse?

- A 2-year-old who has leukemia and two working parents

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development?

- A 4-year-old female

Which statement about crisis theory will provide a basis for nursing intervention?

- A crisis is an acute, time-limited phenomenon experienced as an overwhelming emotional reaction to a problem perceived as unsolvable

Which statement concerning a crisis experience is true and should be used as a guideline for crisis management care? (Select all that apply.)

- A crisis is self-limiting and usually resolves within 4-6 weeks - The earlier the interventions are implemented, the better the expected prognosis - The goal of crisis management is to return the patient to at least the pre-exisiting level of functioning

A rape victim in the emergency department keeps repeating, "I don't know why he did it." Although the nurse does not necessarily give the answer to this juncture, the nurse correctly identifies the motivation for most perpetrators of rape as:

- A desire to dominate and humiliate

Which describes the principle of crisis intervention?

- A directive, time-limited, and goal-directed strategy designed to assist individuals who are experiencing crisis

In the event of an adventitious crisis, which age group would be least in need of crisis intervention?

- A distinction cannot be made

Which scenarios describe completed rape? (Select all that apply.)

- A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. - A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant - A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient

A young child is found wandering alone at a mall. A male store employee approaches and asks where her parents are. She responds, "I don't know. Maybe you will take me home with you?" This sort of response in children may be due to:

- A lack of bonding as an infant

Lilly, a single mother of four, comes to the crisis center 24 hours after an apartment fire in which all the family's household goods and clothing were lost. Lily has no other family in the area. Her efforts to mobilize assistance have been disorganized, and she is still without shelter. She is distraught and confused. You assess the situation as:

- A maturational crisis

Which belief would be least helpful for a nurse working in crisis intervention?

- A person in crisis is incapable of making decisions

Which belief would be least helpful for a nurse working in crisis intervention?

- A person in crisis is incapable of responding to instruction

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

- A person who feels judged or accused of wrongdoing is likely to become defensive - Focus upon identifying problems and acceptable ways of solving them - Establishing a trustful rapport is the initial nursing intervention

The school nurse has been alerted to the fact that an 8-year-old boy routinely play acts as a police officer, "locking up" other children on the playground to the point where the children get scared. The nurse recognizes that this behavior is most likely an indication of:

- A potential symptom of traumatization

Which scenario is an example of an adventitious crisis?

- A riot at a rock concert

Which situation describes consensual sex rather than rape?

- A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision

Which referral will be most helpful for a woman who was severely beaten by her intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?

- A woman's shelter

Nicole is a 28-year-old married patient who comes to the emergency department after being raped on her way home from work. You have been with her as she cries and talks about what happened. She asks you, "What if I am pregnant?" Your response is guided by the knowledge that:

- About 5% of women who are raped become pregnant as a result

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.)

- Acute stress disorder - Depersonalization disorder - PTSD

During a routine health screening, a grieving widow whose husband died 15 months ago reports emptiness, a loss of self, difficulty thinking of the future, and anger at her dead husband. The nurse suggests bereavement counseling. The widow is most likely suffering from:

- Adjustment disorder

A family's home and possessions are lost when a massive forest fire burns out of control. What type of crisis has occurred?

- Adventitious

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both the parents about the uncle's behavior, but did not believe the adolescent. What type of crisis exists?

- Adventitious

When a tornado results in the loss of homes, businesses, and life, the town residents are likely to experience a(n):

- Adventitious crisis

A nursing intervention directed at the psychological needs of an abused woman is to:

- Affirm that the client did not deserve or cause the abuse

Which scenario demonstrates a dissociative fugue?

- After being caught in an extramartial affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing

What symptom can the nurse expect a client diagnosed with depersonalization disorder to manifest?

- Aimless wandering with confusion and disorientation

The stress of being raped often results in suffering similar to people who have witnessed a murder or had a physiological reaction to trauma, resulting in which of the following:

- All of the above (PTSD, anxiety, depression)

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.)

- Allow the patient to talk at a comfortable pace - Place the patient in a private room with a caregiver - Pose questions in nonjudgmental, empathetic ways

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 the patient most vulnerable to abuse?

- Alzheimer's disease

Rape is best described as:

- An act of violence using sex as the weapon

Which health care worker should be referred for critical incident stress debriefing?

- An emergency medical technician (EMT) who treated victims of a car bombing at a mall

A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is:

- Anxious and fearful

A person was admitted at a health care facility following a suicide attempt resulting from family violence. After the crisis is resolved, what should be the next intervention?

- Ask the patient if he or she has a plan to repeat this

The nurse is caring for a depressed patient who was rescued from an earthquake. As part of the counseling and treatment, the nurse wants to assess the patient's family and the patient's stressors. What appropriate action will the nurse take?

- Ask the patient to describe his or her feelings

The nurse is engaged in crisis intervention with a female patient who states, "I have no reason to keep on living." What is the nurse's initial intervention?

- Ask the patient, "Do you have any plan to hurt yourself or anyone else?"

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should:

- Ask what other relatives or friends are available for support

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

- Assess safety and help explore alternatives to reduce dangers

You are discharging Vanessa, a 30-year-old victim of domestic violence from the emergency department. She has sustained bruises and abrasions but no serious trauma. She is fearful that Children's Services will take custody of her daughter. Her daughter has not be harmed and is safe with Vanessa's mother. Which intervention on your part is indicated?

- Assist Vanessa to develop a safety plan for rapid escape should abuse happen again

When the nurse believes the cycle of abuse is escalating and that a woman may be in severe physical danger, the priority nursing intervention is to:

- Assist her to develop a plan to go to a shelter in case of a crisis

A young woman named Carly was raped after closing shift behind the restaurant where she works. Six months have passed and Carly has not been able to return to work, refuses to go out to eat, and feels that she has less value as a woman now that she has been raped. Carly's clinical presentation suggests:

- Avoidance

When a stressful event occurs and the individual is unable to resolve the situation using his or her usual coping strategies, the individual:

- Becomes disorganized and uses trial-and-error problem solving

To best assure the safety of a 3-year-old client whose parent admits to finding it difficult to control their anger, the most appropriate short-term goal would be for the parent to:

- Begin attending anger management training sessions within 2 weeks

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?

- Bruises on extremities

An emergency department nurse prepares to assist with the examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.)

- Camera - Body map - DNA swabs

From a psychosocial perspective, the nurse is most troubled when witnessing the parents of 6-year-old twins ignoring the boys being physically aggressive toward each other because this behavior:

- Can lead to the children developing violence as a coping mechanism

An 11-year-old says, "My parents don't like me. They call me stupid and they wish I was never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child?

- Chronic low self-esteem related to negative feedback from parents

A woman said, "I can't take anymore! Last year my husband had an affair, and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment?

- Clarify what the patient means by "I can't take anymore."

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that the patient is in the acute phase of the rape-trauma syndrome?

- Confusion and disbelief

Which of the following is a likely behavior for a woman attempting to escape a chronically abusive relationship?

- Considering ways to commit suicide

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.)

- Coping mechanisms the patient is using - Signs and symptoms of emotional and physical trauma - Adequacy and availability of the patient's support system

A woman said, "I can't take anymore! Last year my husband had an affair, and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention?

- Coping with the reaction to the daughter's events

In the tertiary prevention method, what measures are taken to assist the survivors of abuse in the healing process? (Select all that apply.)

- Counsel the individuals and families for healing and rehabilitation - Assist the survivors of violence to achieve safety, health, and well-being - Assist in dealing with the legal proceedings against the perpetrator

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patients says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy?

- Denial

Which government entity is charged with coordinating responses to American disasters, particularly in situations in which local and state resources are inadequate to the presenting challenge?

- Department of Homeland Security (DHS)

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

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

A troubled adolescent pulled out a gun in a school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next?

- Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents

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.)

- Development of fears and phobias - Feelings of numbness - Flashbacks, dreams

A nurse driving home from work comes upon a serious automobile accident. The driver gets out of the car with no physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? (Select all that apply.)

- Difficulty using a cell phone - Rapid speech - Trembling

When interviewing an adult victim of abuse, the nurse's best approach is to be:

- Direct and professional

A female nurse had been sexually assaulted as a teenager. She finds it difficult to work with patients who have undergone the same trauma. What is the most helpful response?

- Discussing those feelings with a mental health professional

What reaction is most commonly displayed by rape victims in the immediate aftermath of the rape?

- Disorganization

Perpetrators of sexual assault are often incarcerated but frequently do not undergo therapy. Samuel, convicted of rape and sentenced to 15 years in prison, has asked to see a therapist. The psychiatric nurse practitioner is surprised to learn of the request, as many perpetrators:

- Do not acknowledge the need for change

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?

- Document injuries with a body map

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?

- Emotional

A client who comes to the emergency department states that she has just been raped. She displays a blank face and a rather calm appearance. During the assessment interview she seems unable to believe the event really happened. The nurse can assess this behavior as the client demonstrating a(n):

- Emotional affective response to the rape

A 4-year-old tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This situation can be an example of:

- Emotional violence

An emergency department nurse whispers to a colleague, "That woman is back again. She does the same thing repeatedly. He beats her up, she comes to the emergency department, we stitch her up, they make up, and then he beats her again. Why does she let it keep happening?" What is the colleagues best action?

- Encourage the nurse to discuss this reaction with the supervisor

The nurse is performing crisis intervention for a sexually assaulted patient. What appropriate action should the nurse take to help the patient cope with the crisis? (Select all that apply.)

- Encourage the patient to express feelings in a nondestructive manner - Frequently restate the statements made by the patient during the interview - Guide the patient about maintaining support systems

Secondary effects of abuse often manifest as arrested development in children due to the fact that:

- Energy for development is diverted to coping

The use of patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and:

- Establish trust and rapport

Josefina was raped 6 months ago. Which symptom(s) should you anticipate for long-term successful outcomes? (Select all that apply.)

- Evidence of comfort in relationships - Recognition of the right to be protected from abuse - Anxiety being replaced by calmness - Absence of phobia of being alone

A 12-year-old female finds herself feeling anxious and overwhelmed and seeks out the school nurse to report that, "Everything is changing...my body, the way the boys who were my friends are treating me, everything is so different." It is likely the child is:

- Experiencing a maturational crisis

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 appl.)

- Explain that bathing destroys evidence - Offer the victim a shower after evidence is collected

A nurse works a rape telephone hotline. Communication with potential victims should focus on:

- Explaining immediate steps victims should take

The nurse responding to the hotline call of a rape victim advises her to go to the nearest emergency department for treatment. When the woman states, "I'll think it over while I take a shower." the nurse:

- Explains that doing so could destroy evidence

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:

- Expresses frustration verbally instead of physically

An abuse victim tearfully tells the nurse in the emergency department, "Don't tell my husband that you know he beats me because if he thinks anyone knows, he will beat me again." Based on this information, the most appropriate nursing diagnosis is:

- Fear

The emergency department nurse planning care for a rape victim must realize that the emotional reaction displayed by many rape victims during the initial assessment and treatment is:

- Fear

Following an assessment, the nurse concludes the patient is in phase 2 crisis. What signs and symptoms does the nurse find in this patient?

- Feelings of extreme discomfort

When the client tells the nurse that she was raped by her date several weeks ago, the most likely reason for taking so long to report the incidence is her:

- Feelings of guilt for somehow having caused it

When there is reason to suspect that a child is being abused, the nurse must initially:

- Follow agency policy for reporting

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

- Form a trusting relationship with the nurse

Which outcome indicates the individual is demonstrating a commonly observed but negative coping strategy after a crisis event? (Select all that apply.)

- Gaining 10 pounds over a 6 week period - Losing one's driver license for drunk driving - Offering numerous excuses for not socializing

Which communication technique will the nurse use more in crisis intervention than traditional counseling?

- Giving direction

The nurse caring for a patient in crisis shows signs of a problematic nurse-patient relationship by:

- Giving the patient permission to call him or her at home when the patient 'needs to talk'

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

- Has effective wound healing

A client comes to the crisis intervention clinic and tearfully tells the nurse, "It is so painful! I have thought about it, and I cannot see how I can go on without my partner." The nurse states, "You have resilience and will look back on this as a crisis you were able to manage." Analysis of this interaction reveals that the nurse:

- Has not followed up on the client's verbal cues to suicidal thoughts

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:

- Have been abused

Perpetrators of domestic violence tend to: (Select all that apply.)

- Have relatively poor social skills and to have grown up with poor role models - Believe they, if male, should be dominant and in charge in relationships - Be controlling and willing to use force to maintain their power in relationships - Prevent their mates from having relationships and activities outside the family

The nurse performing the assessment of a wheelchair-bound client suspects that his wife's explanation of how he sustained facial contusions and a broken nose may not be entirely truthful. The nurse should:

- Have the wife wait in the waiting room so her husband can be interviewed in private

Which of the following is an example of a maturational crisis?

- Having one's only child leave home to attend college

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

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

A nurse is caring for a pediatric patient who has severe injuries on his or her face and neck. The nurse says to the nurse manager, "I empathize with the patient; I wish I could make this patient happy by resolving all the problems." What response does the nurse have to the patient?

- Helplessness

What feelings are most commonly experienced by nurses working with abusive families?

- Helplessness regarding the victim and anger toward the abuser

Nathan, a nursing student, is assigned to care for Shawna, who is recovering from injuries received during an episode of domestic violence, the third such assault for which she has received treatment. Nathan left home at age 17 to escape an abusive father. Which statements about Nathan's situation are accurate? (Select all that apply.)

- His personal experiences give him special insight into the needs of this patient - His experiences are likely to make him more empathetic towards victims - He may experience overwhelming emotions as a result of caring for abuse victims - He would likely benefit from clinical supervision related to caring for abuse victims

A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that growing up. He always apologizes and regrets hurting me." What risk factor is most predictive for the husband to become abusive?

- History of family violence

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?

- Honeymoon

An elderly woman who has been abused by her caregiver daughter tells the nurse, "You don't have to worry about me. My daughter cried and apologized. She promised me she will never hit me again." The nurse can assess that this is the stage in the cycle of violence known as:

- Honeymoon

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

- How the victim will explain her decision to leave

A nurse is teaching patients in a primary health care center how to escape and avoid being a victim of abuse by their partners. Which action of a participant indicates effective teaching? (Select all that apply.)

- Identifying the signs of escalation and violence - Packing a bag with money and birth certificates - Leaving the place immediately if there are signs of violence

The nurse interacts with a patient at the crisis center. The patient speaks of distressing events and makes dismissive comments. What diagnosis should the nurse make from the patient's symptoms?

- Ineffective denial

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

- Ineffective individual coping

A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, "I cannot teach nor do ant research. My mind is totally occupied with these false accusations." What is the priority nursing diagnosis?

- Ineffective role performance related to distress from false accusations

What is the primary factor that makes an event a crisis?

- Ineffectiveness of one's usual coping strategies

Which statement would be an appropriate long-term outcome for a rape client? The client will:

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

Anticipatory teaching of a rape victim should include information that a common survivor problem that often develops during the long-term reorganization phase of rape trauma syndrome is:

- Intrusive thoughts

The principle most useful to a nurse planning crisis intervention for any patient is that the patient:

- Is experiencing a state of equilibrium

A person with history of abusing an intimate partner says, "When my partner leaves home, I think it's because she's meeting someone she likes better than me." Which emotion is most evident by this comment?

- Jealousy

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.)

- Keep a cell phone fully charged - Have the phone number for the nearest shelter - Secure a supply of current medications for self and children - Assemble birth certificates, social security cards, and licenses - Determine a code word to signal children when it is time to leave

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

- Levels of anxiety and coping responses - Observations of the family's patterns of coping - Indications or patterns of violence

Which event leads to the development of a situational crisis in patients?

- Loss of a job

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:

- Maintaining physiologic stability

A pregnant woman is in a relationship with a male who routinely abuses her. Her unborn child may engage in high-risk behavior as a teen as a result of:

- Maternal stress

A man is having difficulty adjusting to becoming a father. He has not bonded with his newborn and frequently stays out at night drinking with friends. Which type of crisis is evident?

- Maturational

After celebrating the 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?

- Maturational

Lauren brings her 4-year-old daughter, Mikayla, to the emergency department and states that Mikayla has be "acting funny." Lauren states, "She touches her vagina and rubs herself down there all the time and she never did that before. She drew me a picture showing two people with one on top of the other and said they were 'doing sex' and I saw her acting that out on her dolls too. I didn't know where else to go." Based on Lauren's description, you suspect that:

- Mikayla has been sexually abused

A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurse provides emergency supplied of insulin to persons with diabetes and help transfer patients in skilled nursing facilities that have electrical power. Which aspects of disaster management have these nurses fulfilled? (Select all that apply.)

- Mitigation - Response

Which statistic concerning rape is true?

- Most male rape victims do not report the crime

Which statement reflects a truth about rape?

- Most rapes are planned

Which statement is an accurate description of sexual assault?

- Most rapes occur in the home

Which situation has the potential for early crisis intervention to occur?

- Mrs. R. tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist

Which racial identification places a woman at the greatest risk of being sexually assaulted in her lifetime?

- Multiracial

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:

- Name two community resources for help

Which agency provides coordination in the event of a terrorist attack?

- National Incident Management System (NIMS)

What distinction can be made between abuse and neglect?

- Neglect is a failure to provide; abuse is a failure to control aggression

Which signs and symptoms are associated with rape-trauma and rape-trauma response? (Select all that apply.)

- Outbursts of anger - Major depressive disorder - Flashbacks - Amnesia for the event

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.)

- Parental sessions to teach childrearing practices - Anger management counseling for the father - Continuing home visits to give support

What nursing intervention can be incorporated to assist parents in stopping the use of corporal punishment to discipline their child?

- Parents are referred to parenting resources to learn alternative approached to discipline

What is the priority concern of the crisis intervention nurse?

- Patient safety

What are the two initial goals for crisis interventions?

- Patient safety and anxiety reduction

Mason and Charlie, both 16 years old, were involved in a bad car accident in which they were both passengers. Mason spoke with a counselor about the incident once and has been able to move forward with little dysfunction. Charlie has been experiencing anxiety and an inability to concentrate in school even after numerous counseling sessions. What is the most likely reason that accounts for the difference in the way the individuals who experience the same event are affected emotionally by that event?

- Perception of the event

During which crisis phase does a patient exhibit serious personality disorganization, depression, and confusion?

- Phase 4

Which problem is observed in children who regularly witness acts of violence in their family? (Select all that apply.)

- Phobias - Low self-esteem - Major depressive disorder - Posttraumatic stress disorder

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?

- Physical

What findings are important for the nurse to document at the initial assessment of a case of domestic violence? (Select all that apply.)

- Physical evidence of sexual abuse, whenever possible - Body map to describe the injuries along with explanations - Verbatim statements of who caused the injury and when

An adult has recently been absent from work for 3-day periods on several occassons. Each time, the individual returned to work wearing dark glasses. Facial and body bruises were apparent. What is the occupational health nurse's priority assessment?

- Physical injuries

Care planning for the rape victim is facilitated if the nurse understands that rape trauma syndrome is actually a variant of:

- Posttraumatic stress disorder

A nurse assesses a victim of intimate partner violence and observes bruises, scar, lacerations, burns, and wounds in various stages of healing. The patient says, "He's going to kill me next time if I don't do something." Which nursing diagnosis has the highest priority?

- Powerlessness

An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family? Which nursing diagnosis applies?

- Powerlessness

The nurse is caring for a victim of elder abuse. What are the issues addressed in abuse protection support for older adults? (Select all that apply.)

- Prevention of infliction of physical, emotional, or sexual harm - Identification of high-risk, dependent elder relationships - Prevention of neglect of the older adult's basic necessities of life

What is the best description of a psychiatric advance directive plan?

- Proactive method of addressing a crisis situation before it occurs

Mindy is the nurse caring for Caitlin, who was raped the night before. Caitlin is considering the morning-after pill to prevent a possible pregnancy that may have resulted from the rape. Caitlin is concerned and states that she does not believe in abortion. Which of the following is the most appropriate action Mindy could take in this situation?

- Provide Caitlin with medication education

Before a victim of sexual assault is discharged from the emergency department, the nurse should:

- Provide referral information verbally and in writing

A patient is treated in the emergency department for injuries sustained while vacationing hundreds of miles away from home. To best meet the patient's emotional needs, the nurse should:

- Provide temporary support by arranging shelter and contacting the patient's friends

A victim of 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:

- Provide written information about physical and emotional reactions this person may experience

In the acute phase of rape trauma syndrome, nursing interventions should focus on:

- Providing client support and safety

What are the three levels of help that can be provided to the abusive family to build a healthy therapeutic environment? (Select all that apply.)

- Providing family therapy - Arranging visits by a nurse - Providing economic support

Tara, a 19-year-old freshmen college student, arrives for a follow-up appointment at the mental health clinic where you work. She had been previously been seen in the clinic for crisis intervention three weeks ago after being raped. Tara states, "My mom says I was asking for trouble because of the way I was dressed at the party. She says when girls dress so sexy, men can't help themselves." Your response is guided by the knowledge that:

- Rape is an act of violence, aggression, and power, not an expression of sexual needs

After the bomb explosions at the Boston Marathon in 2013, members of the community donned t-shirts that said, "Boston Strong." Which phase of disaster management continuum is evident by this behavior?

- Recovery

A community health nurse starts working with the family of a victim of domestic abuse. What strategies for primary prevention are helpful in this case?

- Reducing stress in the family - Increasing amount of social support - Increasing use of coping skills

A battered woman has been referred to a woman's shelther. When the woman's abuser demands to be told where she is, the nurse:

- Refuses to provide any information

A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. The action the nurse should take is to:

- Report and document the request

What safety-related responsibility does the nurse have in any situation of suspected abuse?

- Report suspected abuse to the proper authorities

What is a nurse's legal responsibility if child abuse or neglect is suspected?

- Report the suspicion according to state regulations

Emergency response workers arrive in a community after a large-scale natural disaster. What is the workers' first action?

- Report to the incident command system (ICS) center

A patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?

- Reports feeling stronger and having a sense of hopefulness

An adult has cared for a debilitated parent for 10 years. The parent's condition has recently declined, and the HCP recommended placement in a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to:

- Resolving the feelings associated with the threat to the person's self-concept

A nurse is assessing an infant and concludes that he or she has shaken baby syndrome. Which symptoms has the nurse found in the infant? (Select all that apply.)

- Retinal hemorrhages - Bulging fontanels - Respiratory problems

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner 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?

- Risk for injury related to physical abuse from partner

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?

- Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision

Ron is a victim of assault and has revealed to his family and friends the fact that he was raped. The family reacts with horror and disgust, and the nurse caring for Ron recognizes that:

- Ron's family will also need support

Which of the following persons has the highest risk factors for physical abuse?

- Rose, a 77-year-old woman living with her daughter and son-in-law

When treatment for injuries sustained during an incident of abuse is sought from the primary physician, the client is receiving:

- Secondary prevention

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?

- Secure additional resources for the mother's evening and night care

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes 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?

- Severe

A one-year-old child has respiratory problems and is vomiting. Examinations show the child has bulging fontanels and a retinal hemorrhage. What should the nurse suspect?

- Shaken baby syndrome

A nurse working in a trauma center has been accused of getting overly attached to some patients. The nurse has even called some patients after they are discharged and tries to give advice about general health issues. What is the best course of action for the nurse?

- Share personal feelings with trained professionals

An adult has a family history of colon cancer, so this adult has screening colonoscopies every 5 years. At age 55, the colonoscopy reveals a malignant tumor in the ascending colon. The nurse should assess this adult for which type of crisis?

- Situational

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing?

- Situational

Which type of crisis arises from events that are extraordinary, external rather than internal, and often are unanticipated?

- Situational

While conducting the initial interview with the patient in crisis, the nurse should:

- Speak in short, concise sentences

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

- Strong negative feelings interferes with assessment and judgment

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?

- Support the victim to separate issues of vulnerability from blame

A victim of spousal violence comes to the crisis center seeking help. Crisis intervention strategies the nurse uses will focus on:

- Supporting emotional security and reestablishing equilibrium

Nicole alternates between sobbing and being quiet and withdrawn. Which of the following best illustrates best practice in giving care to a patient who has just been sexually assaulted?

- Supportive: "I am going to stay with you. We can talk as long as you want to."

To provide treatment and support, the nurse should realize that the most common sequela(e) of acquaintance rape is the development of:

- Symptoms of sexual distress

Which situation demonstrates use of primary care related to crisis intervention?

- Teaching stress reduction techniques to a first-year college student

The nurse is meeting with a woman who was raped the previous week. The nurse's client education plan includes talking about the possibility of experiencing intrusive thoughts, increased motor activity, and fears and phobias in the next few weeks. The reason for this intervention is:

- That anticipatory guidance allows planning to decrease stress

A victim of 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?

- The acute phase

What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver?

- The caregiver was neglected as a child

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

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

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

- The children hesitate to interact with the nurse

Which assumption serves as a foundation for the use of crisis intervention?

- The individual is mentally healthy but in a state of disequillibrium

Which data obtained during a family assessment could be considered an early indicator of the greatest potential for family-focused abuse?

- The mother's brother is in jail for assault and battery

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me get my life back in balance." The nurse responds, "I think we should have two more sessions to explore why your reactions were so intense." Which analysis applies?

- The nurse is having difficulty terminating the relationship

A nurse is conducting crisis intervention for a patient who is a victim of physical assault and learns that the patient is confused and overwhelmed. Which strategy does the nurse implement while interacting with the patient to make the patient feel more comfortable?

- The nurse summarizes information given by the patient

The nurse is caring for a patient with a rape-trauma syndrome. What outcome shown by the patient after 8 weeks indicates effective crisis intervention?

- The patient concentrates on the given task

A person comes to the health care facility with a bleeding head injury and some bruises to both hands. What signs would indicate this person is a victim of domestic abuse? (Select all that apply.)

- The patient has weak and nervous behavior - The patient's explanation is inconsistent - The patient gives hesitant explanations

An individual comes to the crisis clinic for a first visit and reports not sleeping well, anxiety, and excessive crying. These symptoms occurred shortly after a sudden job loss and losing his or her home to a tornado that devastated the town in which the patient lives. Which of the following statements regarding crisis accurately describes the individual's situation?

- The patient is experiencing both a situational and an adventitious crisis

An adult recently diagnosed with multiple sclerosis says, "I'm worried I won't be able to support for my family or send my children to college." This person begins drinking alcohol heavily and omitting prescribed medications. what is the likely cause of the patient's behavior?

- The patient is in a state of situational crisis

An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be:

- The perpetrator will recognize destructive patterns of behavior and learn alternate responses

The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? (Select all that apply.)

- The police department - An abuse hotline - A responsible friend or family member - A domestic violence shelter

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

- The sexual abuse will cease immediately

The victim of abuse can expect the abuse to worsen when:

- The victim moves toward independence from the abuser

The risk of elder abuse in a home is best determined by assessing:

- The vulnerability of the elder and the stress of the caregiver

The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and the elderly due to:

- Their limited options

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss?

- Throw flowers on the lake at each anniversary date of the accident

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next?

- Tricyclic antidepressant (TCA)

A child placed in a foster home after being removed from abusive parents is apprehensive and overreacts to environmental stimuli. The foster parents ask how to help the child. Which interventions should the nurse suggest? (Select all that apply.)

- Use a calm manner and low voice - Maintain simplicity in the environment - Explain and reinforce reality to avoid distortions

Tori is the nurse working with Carter and other members of the community after the tornado. As the weeks go by, she begins to feel anxious and distressed. She speaks to her nurse mentor about her feelings. Which of the following may Tori be experiencing?

- Vicarious traumatization

Which statement reflects a fact about family violence?

- Violence occurs in families of all backgrounds

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 physiological response would be expected for this patient?

- Vital signs return to normal

When does a patient have symptoms of self-hatred and depression?

- When the patient has chronic low self-esteem

Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present:

- With vague physical complaints such as insomnia or pain

Which of the following are myths surrounding rape? (Select all that apply.)

- Women are usually raped by a stranger - Most rapes occur away from the home areas such as alleys and behind buildings - Documented rape cases include women from 8 to 70 years old - Rape is usually an impulsive, spur-of-the-moment decision by the rapist - Unless the assailant is armed, most women should be able to get away and avoid the rape

A woman comes to the crisis intervention clinic expressing concern that her 16-year-old is using illegal drugs in their home. The nurse will:

- Work with the patient to set goals that are mutually acceptable

You are caring for Connor, an 8-year-old boy who has been diagnosed with reactive attachment disorder. Which of the following nursing outcomes would be the most appropriate to achieve?

- Writes or draws feelings in a journal

A nurse assesses an individual who commonly experiences anxiety. Which comment by the person indicates the possibility of obsessive-compulsive disorder?

- "I check where my keys are eight times."

Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The solider was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention?

- "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me."

A client experiencing moderate anxiety says, "I feel undone." What would be the appropriate response by the nurse?

- "I'm not sure I understand. Give me an example."

Jamie, age 24, has been diagnosed with a dissociative disorder following a traumatic event. Jamie's mother asks you, "Does this mean my daughter is now crazy?" Your best response would be:

- "Jamie is dealing with the anxiety associated with the trauma by separating herself from it. With treatment, she can get back to her previous level of functioning."

Isabel is a straight-A student, yet she suffers from severe test anxiety and seeks medical treatment. The nurse interviews Isabel and develops a plan of care. The nurse recognizes effective teaching about mild anxiety when Isabel states the following:

- "Mild anxiety is okay because it helps me to focus."

Which statement or statements made by the nurse demonstrates an understanding of the effective use of relaxation therapy for anxiety management? (Select all that apply.)

- "Muscle relaxation promotes the relaxation response." - "Show me how you learned to deep breathe in yesterday's therapy session." - "You've said that going to group makes you nervous, so let's start relaxing now." - "I've given you written descriptions for the various relaxation exercises for you to review."

A homebound patient diagnosed with agoraphobia has been receiving therapy at home. The nurse recognizes effective teaching when the patient states the following:

- "My risk for agoraphobia is increased by my family history."

A store clerk was killed during a robbery two 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.

- "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

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.

- "Use short, simple sentences and keep the environment calm and protective."

Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially has feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response?

- Altruism

Which experiences are most likely to precipitate PTSD? (Select all that apply.)

- An adolescent was kidnapped and held for 2 years in the home of a sexual predator - A passenger was in a bus that overturned on a sharp curve and tumbled down an embarkment - An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks

A client in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the client?

- An interview room furnished with a desk and two chairs

Which statement about structural dissociation of the personality is true?

- An organic basis exists for this type of disorder

A woman just received notification that her husband has died. She approached the nurse who cared for him during his last hours and says angrily, "If you have given him your undivided attention, he would still be alive." How should the nurse analyze this behavior?

- Anger is an expected emotion in an adjustment disorder

When alprazolam is prescribed for a client who experiences acute anxiety, health teaching should include which instruction?

- Avoid alcoholic beverages

A soldier who served in a combat zone returned to the United States. 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 PTSD?

- Avoidance

A woman is 5'7'', 160 lb., and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller, and in social settings, conceals both feet under a table or chair. Which health problem is likely?

- Body dysmorphic disorder

A child who was physically and sexually abused is at great risk for demonstrating which characteristics?

- Bullying and abusing others

The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient: (Select all that apply.)

- Avoids people and places that arouse painful memories - Experiences flashbacks or reexperiences the trauma - Experiences symptoms suggestive of a heart attack - Demonstrates hypervigilance or distrusts others - Feels detached, estranged, or empty inside

The activity of gamma-aminobutyric acid (GABA) contributes to a slowing of neural activity. Which of the following drugs facilitate the action of GABA?

- Benzodiazepines

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.

- "Her death is a terrible loss for you."

Which assessment questions would be most appropriate for the nurse to ask a client with possible obsessive-compulsive disorder? (Select all that apply.)

- "Are there others in your family who must do things in a certain way to feel comfortable?" - "Is it difficult to keep certain thoughts out of your awareness?" - "Do you do certain things over and over again?"

The nurse assesses a client who reports loneliness and episodes of anxiety. Which statement by the client is most likely if this client also has agorophobia?

- "Being afraid to go outside seems ridiculous, but I can't go out the door."

The nurse is providing care for a patient demonstrating behaviors associated with moderate levels of anxiety. What question should the nurse ask initially in attempting to help the patient de-escalate the anxiety?

- "Can you identify what was happening when your anxiety began to increase?"