HA - Chapter 10: Assessing for Violence

A nurse is educating a victim of intimate partner violence about a safety plan. The nurse should include which of the following? "Do not tell people about the abuse; it will only anger the abuser." "Contact your neighbors to arrange for a place to go should a disruption occur." "Have a code word to use with your children, family, and friends that indicates you need help." "Do not remove weapons in the house; this will only upset the abuser."

"Have a code word to use with your children, family, and friends that indicates you need help." A victim of intimate partner violence should have a code word they can use when a disruption occurs so that children, family, or friends know they need assistance. Telling people about the abuse, such as close friends and neighbors, can save the victim's life. Staying at a neighbor's house is not recommended because it is too close to the home. It is recommended that weapons be removed from the home to prevent injury.

The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation? "I have not seen my parents in 6 months; they live only 30 minutes away." "My boyfriend hits the kitchen wall with his fist just inches from my head." "My boyfriend says I'm stupid even though I have a degree in education." "If my boyfriend wants me to know something, he has the kids tell me."

"I have not seen my parents in 6 months; they live only 30 minutes away." Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go. Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them self. A perpetrator uses children to relay messages to exert power or control the victim.

The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? "Is your partner being mean to you?" "Why do you think your husband has beaten you?" "It looks like someone has hurt you. Tell me about it." "Can you describe the person who did this to you?"

"It looks like someone has hurt you. Tell me about it." The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize her thoughts and feelings. Asking if the partner is being mean or why the client thinks the husband has beaten her already assume that the client has been abused. Asking about the person who did this to the client would be ineffective be survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly.

A nurse is assessing a client for elder abuse. Which statement should the nurse ask first? "Tell me about your typical day." "Do you take your medications regularly?" "How often do you bathe?" "Tell me about your caregiver."

"Tell me about your typical day." Asking the client to tell the nurse about their typical day allows the nurse to understand the client's routine. Asking about medications and how often they bathe may reveal that the client has been neglected but this is not the best answer in this situation. The client may not feel comfortable talking about their caregiver for fear of retribution.

The teaching nurse is explaining the Abuse Assessment Screen to a new nurse. The teaching nurse determines understanding of the instrument when the new nurse makes which of the following statements? "The tool measures acts of abuse the client experienced over the past year." "The tool measures the severity of the abuse over the past 6 months." "The tool assesses the frequency of abuse over the past month." "The tool assesses the client's level of risk for injury."

"The tool measures acts of abuse the client experienced over the past year." The Abuse Assessment Screen measures the number and severity of abuse the client has experienced over the past year. The severity or risk of injury from abuse is measured by the Danger Assessment tool. The frequency of abuse is measured by the Hurt, Insult, Threaten, Scream (HITS) tool.

What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue? "What can I tell you about abuse?" "I know you have been abused. Please tell me about it." "Abuse is more prevalent than most people think." "What would you like me to know?"

"What would you like me to know?" Open-ended questions, such as "What would you like to know?" "How can I help you understand?" or "What would you like me to know?" are especially helpful if a client appears uncomfortable. It would be inappropriate for the nurse to ask what she can tell the client about abuse or to tell the client that the nurse knows the client has been abused. While discussing the prevalence of abuse might help increase the client's knowledge, it might not make her feel any more comfortable about the situation or ready to share information.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? "He threw me against the wall and starting punching my face." "He yells at me for not having dinner waiting for him when he came home." "He calls me stupid and incompetent, asking himself why he ever married me." 'He tells me that he is sorry and that he will never hit me again."

'He tells me that he is sorry and that he will never hit me again." During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again until the next time. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1 or tension building.

A nurse assesses a client who was physically assaulted by his brother. The nurse learns that the client has been punched and kicked. After marking the area of injury on the body map, what score should the nurse document for this abuse? 1 3 4 5

3 The nurse should document the abuse score as 3. An abuse score of 1 describes the threat of abuse by weapons. Beating up and severe contusion is given a score of 4 and head injury and internal injury is given a score of 5.

Which child should a nurse suspect may be a victim of child abuse? A three-year-old who is unable to put words together to make a sentence A five-year-old who cries when the mother refuses to allow him to sit on her lap A toddler with an unsteady gait and frequently loses balance when running A seven-year-old who still wets the bed at least three nights a week

A three-year-old who is unable to put words together to make a sentence A three-year-old should have a vocabulary of about 900 words and be able to say 3- or 4-word sentences. A three-year-old who is not speaking at this level may be a victim of abuse or neglect. A five-year-old should be in the psychosocial development stage of initiative versus guilt. Separation from the parents should have been mastered during the toddler stage and the preschooler is ready to assert some independence. A toddler is from age 1 to 3 years. Toddlers are beginning to walk and often have a wide stance to maintain balance. Falls are common at this age. Bedwetting or enuresis may occur in some children up to the age of 10 years.

Which of the following is true of psychological abuse? Psychological abuse is easy to define and diagnose. An abuser may use psychological behaviors such as belittling, exploiting, denigrating, or remaining emotionally unresponsive. The majority of children experiencing psychological abuse do not use effective coping mechanisms. Psychological abuse of children does not affect long-term development.

An abuser may use psychological behaviors such as belittling, exploiting, denigrating, or remaining emotionally unresponsive. Psychological abuse involves the use of constant insults or criticism, blaming the victim for things that are not the victim's fault, threats to hurt children or pets, isolation from supporters (family, friends or coworkers), deprivation, humiliation, stalking and intimidation, and manipulation of various kinds, such as threats of suicide. Psychological abuse, also known as emotional abuse, has been defined as "any act including confinement, isolation, verbal assault, humiliation, intimidation, infantilization, or any other treatment which may diminish the sense of identity, dignity, and self-worth."

The nurse suspects a child is a victim of abuse. What observation caused the nurse to make this clinical determination? Hair needs to be combed Has a small hole in the shirt Wears shorts and tennis shoes Appears younger than stated age

Appears younger than stated age Abused children may appear younger than the stated age due to developmental delays or malnourishment. Mussy hair, a hole in the shirt, and wearing shorts and tennis shoes are not observations that indicate that the child is a victim of abuse.

The nurse helps with a community health fair and suspects that one young girl may be a victim of human trafficking. What did the nurse observe to come to this conclusion? Select all that apply. Avoids eye contact Provides a street address Wears clothes that are too big Appears anxious when around people Has bruises around the wrists and forearms

Avoids eye contact Wears clothes that are too big Appears anxious when around people Has bruises around the wrists and forearms Common indicators that victims of human trafficking might exhibit include avoiding eye contact, appears malnourished as evidenced by clothes that are too big, demonstrating anxious behavior, and having signs of physical abuse. Victims of human trafficking are unable to provide a home address.

A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score? Beating up and severe contusions Punching and kicking Head injury and internal injury Threat of abuse by weapons

Beating up and severe contusions An abuse score of 4 corresponds to beating up and severe contusions. Punching and kicking are given a score of 3. Head injury and internal injury are rated a score of 5. Threat of abuse by weapons is given a score of 1.

Which of the following would the nurse identify as indicating psychological or emotional abuse? Select all that apply. Calling the victim names Threatening to hit the victim Forcing the victim to perform a degrading or humiliating act Throwing things at a victim Controlling how the family's money is spent Not allowing the victim to seek care for an injury

Calling the victim names Threatening to hit the victim Forcing the victim to perform a degrading or humiliating act Calling the victim names; promising, swearing, or threatening to hit the victim; and forcing the victim to perform degrading or humiliating acts are examples of emotional abuse. Throwing things at the victim is an example of physical abuse. Controlling the finances and spending is an example of financial abuse. Interfering with a victim's access to health care for injuries is an example of physical abuse

When describing the cycle of violence to a community group, the nurse explains that the first phase usually is: Somehow triggered by the victim's behavior Characterized by tension-building and minor battery Associated with loss of physical and emotional control Like a honeymoon that lulls the victim

Characterized by tension-building and minor battery The cyclic behavior begins with a time of tension-building arguments, progresses to violence, and settles into a making-up or calm period.

While performing an initial assessment on a new 24-year-old female client, the nurse determines the client may be at risk for intimate partner violence when which of the following information is obtained? Select all that apply. Client is currently unemployed. Client describes self as a loner. Client reports an unplanned pregnancy. Client earned an associate degree. Client denies drinking alcohol or taking drugs.

Client is currently unemployed. Client describes self as a loner. Client reports an unplanned pregnancy. Individual risk factors for intimate partner violence include, but are not limited to, low self-esteem, low income, low academic achievement, young age, depression, heavy alcohol and drug use, having few friends or no support system, and unplanned pregnancy. This client is exhibiting several risk factors for domestic violence: unemployment, lack of friends/a support network, and an unplanned pregnancy.

A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? Apply ice to the bruise on the client's face to reduce swelling Conduct a forensic interview Assess the client for signs of psychological abuse Determine whether the boyfriend was abused as a child

Conduct a forensic interview If a nurse discovers signs of sexual abuse, including rape, on assessing a client, the nurse should conduct a forensic interview to gather data for potential legal proceedings. The other answers are of lesser priority than conducting a forensic interview.

During a general routine screening, a nurse identifies sexual assault. What is a priority nursing action? Consult a sexual assault nurse examiner (SANE). Perform a Hurt, Insult, Threaten, Scream (HITS) assessment on the client. Administer the Danger Assessment tool. Ask the client if they knew the perpetrator.

Consult a sexual assault nurse examiner (SANE). A sexual assault nurse examiner (SANE) should be consulted if sexual assault is identified. The SANE will obtain additional information and evidence that may be used in court. The HITS tool is used to assess the frequency of abuse. The Danger Assessment tool is used to determine a client's risk of injury due to intimate partner violence. Asking if the client knew the perpetrator will be done later, but the most important action is to obtain and preserve the evidence.

During a group session a victim of intimate partner violence describes the events that led up to the most recent episode of abuse. If using the Tension Building/Explosion Model, what should the nurse expect the victim to describe? Select all that apply. Guilt Set-up Criticism Battering Honeymoon

Criticism Battering Honeymoon In the Tension Building/Explosion Model, there are three phases in the cycle of violence. The first phase is criticism, followed by battering, and ending with the honeymoon phase. Guilt and set-up are phases within the Cycle of Domestic Violence model.

A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment? Danger Assessment Screen Abuse Assessment Screen Burgess-Partner Abuse Scale Beck Depression Inventory

Danger Assessment Screen The Danger Assessment Screen developed by Jacquelyn Campbell and colleagues is a useful tool for assessing the risk that either the adult survivor or perpetrator will commit homicide. It would be appropriate to use when conducting a lethality assessment. The Abuse Assessment Screen and Burgess-Partner Abuse Scale are appropriate tools to use to screen for violence and abuse. The Beck Depression Inventory is used to screen for depression.

During the assessment of an adult woman at the clinic, the nurse finds indications that the client is a victim of abuse. When documenting findings, the nurse knows that it is important to be what? (Mark all that apply.) Sympathetic Consoling Descriptive Non-biased Detailed

Descriptive Non-biased Detailed When documenting objective data, it is important to be detailed, be descriptive, and note findings without bias. Documentation should not be sympathetic or consoling.

Based on findings during assessment, a nurse asks a client to fill out a danger assessment questionnaire. Which of the following is the best rationale for this intervention? Determine the client's risk for becoming a victim of intimate partner violence Determine the client's risk for abusing her children Determine the client's risk for becoming a victim of homicide Determine the client's risk for becoming a victim of sexual abuse

Determine the client's risk for becoming a victim of homicide The purpose of the danger assessment questionnaire is to determine the level of the client's risk for becoming a victim of homicide. Evidence of intimate partner violence should have already been established by the nurse's assessment before the nurse asks the client to complete the danger assessment. The intent of the danger assessment is not to determine the client's risk for abusing her children or becoming a victim of sexual abuse.

The nurse plans to assess for abuse after escorting a school-age child into a bed space in the emergency department. What finding caused the nurse to make this decision? Fractured leg Sprained ankle Dislocated shoulder Lacerations of both lower legs

Dislocated shoulder A dislocated shoulder is an indication of physical abuse. A sprained ankle, fractured leg, or lower extremity lacerations are not necessarily indications of physical abuse.

A client with advanced Alzheimer disease becomes agitated during lunch with other clients in the dining area. What is the first action of the nurse? Ask the client to stop being disruptive. Distract and redirect the client to a quiet area. Administer an antipsychotic medication promptly. Call for security and have the client escorted to their room.

Distract and redirect the client to a quiet area. The best course of action for a client with advanced Alzheimer disease who becomes agitated is to move them to a quiet, safe area and then distract and redirect the client. Asking the client with advanced Alzheimer disease to stop being disruptive may cause further agitation. Before calling security, the nurse should attempt to redirect the client. Least invasive measures should be used first before notifying security or administering medication.

The nurse assesses a client for exposure to violence. Which question that is answered affirmative indicates that the client has been abused? Select all that apply. Do you feel unsafe in your home? Are you afraid of anyone in your home? Has anyone in your home ever hurt you? Has anyone ever threatened you in public? How long have you been in your relationship?

Do you feel unsafe in your home? Are you afraid of anyone in your home? Has anyone in your home ever hurt you? Has anyone ever threatened you in public? Questions that are answered affirmative indicate the client has been abused and include the following: Do you feel unsafe in your home; Are you afraid of anyone in your home; Has anyone in your home ever hurt you; and Has anyone ever threatened you in public. Asking about the length of time the client has been in a relationship is not a question to assess for abuse.

The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing? Emotional abuse Minimizing Intimidation Blaming

Emotional abuse Emotional abuse refers to the victim being put down or made to feel bad about them. The perpetrator makes light of abuse and says abuse did not occur through minimizing and blaming. Intimidation makes the victim afraid through the use of looks, action, or gestures.

When preparing a discussion about violence, which of the following would the nurse include? Abuse is primarily limited to lower socioeconomic groups. Family violence is a public health problem. Males experiencing intimate partner abuse have more options for help. The majority of states now require the reporting of child abuse.

Family violence is a public health problem. Historically, family violence was viewed as a private matter, but in reality, it is a public health problem with a significant impact on health care systems. Abuse is not limited to one economic level, gender, age, or educational level, but can occur in any population. Males also suffer from victimization; however, they may have fewer options for assistance as there are few if any facilities that offer shelter to male victims. All 50 states now mandate child abuse reporting.

The nurse is concerned that an older community member is being abused by an adult son however will not report the abuse or seek help. What could be a reason for this older adult to refrain from reporting the abuse? The abuse is not that bad The older adult loves the son Fear of being institutionalized The son provides companionship

Fear of being institutionalized Elder abuse is often difficult to assess because of the older person's hesitancy to report the abuse. Reasons why abuse is not reported include the fear of being institutionalized. Other reasons why the abuse is not reported include mistrust of law enforcement, family relationship that may create feelings of guilt, burden, dependence, of fear of abandonment. It is unlikely that the abuse is not being reported because the abuse is not that bad, the older adult loves the son, or because the son provides companionship.

A nurse is interviewing a woman who has been physically abused by her husband. When the nurse asks about the husband's background, the client explains that in their native country, women are still viewed as inferior to men, and that it is common for husbands to beat their wives. Which theory of family violence does this example best support? Biological theory Feminist theory Social learning theory Cycle of violence theory

Feminist theory The feminist theory of family violence contends that male/female inequity in patriarchal societies leads to violence. According to the biological theory of family violence, physiologic changes from childhood trauma, head injuries, or through heredity cause violent behavior. Social learning theory states that violence is a learned behavior from childhood. According to the cycle of violence theory, abuse occurs in a predictable pattern.

A nurse performs an assessment on a physically, mentally, and sexually abused spouse. Which action by the spouse should the nurse categorize as psychological abuse? Forcing the victim to perform sexual acts against her will Humiliating, depriving, and intimidating the victim Preventing the victim from keeping a job Refusing to help the victim when injured

Humiliating, depriving, and intimidating the victim Humiliating, depriving, and intimidating the victim is an example of psychological abuse. Forcing the victim to have sex against her will is a form of sexual abuse. Preventing the victim from keeping a job is a form of economic abuse. Refusing to help the victim when injured is a form of physical abuse.

Which of the following is not a true statement about intimate partner violence? One in every three women worldwide is a victim of intimate partner violence at some point in her life. Intimate partner violence is based on the abuser's need to maintain power and control over the victim. The annual cost in the United States for intimate partner violence exceeds $4 billion for medical and health services, and over $1 billion for lost productivity. Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex. Intimate partner violence, as defined by the Family Violence Prevention Fund, "is a pattern of assaultive behavior and coercive behavior that may include physical injury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion," and IPV "affects millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background."

Johnny is a 5-year-old boy who comes to the clinic for his scheduled injections. Which physical indications would lead you to suspect child abuse? Bruising on the upper portion of his buttocks. Regular pattern of circular, coin-sized reddened areas on his back. Irregular pattern of small, circular reddened areas with healing blisters on various parts of his body. Crying when he sees the needle for the injection.

Irregular pattern of small, circular reddened areas with healing blisters on various parts of his body. Abnormal findings consistent with abuse include scars, bruises, burns, welts or swelling on face, breasts, arms, chest, abdomen, or genitalia, including evidence of cigarette or cigar burns.

The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client? Low self-esteem Risk for infection Readiness for enhanced family relationship Readiness for enhanced family health management

Low self-esteem Since the client has been admitted in the past for injuries caused by intimate partner violence, the most appropriate diagnosis would be an actual one such as Low Self-Esteem related to lack of confidence related to presence of prolonged physical, sexual, and emotional abuse. There is no evidence that the client is at risk for infection. There is no evidence that a wellness diagnosis would be appropriate for the client at this time.

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? Undiagnosed eye disease Need for corrective lenses Undiagnosed neurologic disease Nerve damage caused by repeated eye injuries

Nerve damage caused by repeated eye injuries Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses.

Which of the following is a stage in Walker's cycle of violence? Reporting the problem. Hiding the abuse. Period of reconciliation. Ending the relationship.

Period of reconciliation. Walker's Cycle of Violence explains the cyclic nature of violence. Phase 3 of this cycle is the honeymoon phase and is described as a period of reconciliation. This phase begins after an incident of battery. The abuser is loving, promises never to abuse the victim again, and is very attentive to the victim.

Nursing students are learning about human violence. The instructor is explaining key differences among various forms and how the differences affect assessment and intervention. What would the instructor explain is a key difference between violence against older adults and intimate partner violence? Perpetrator Age Support people Family involvement

Perpetrator Violence against older adults is intentional or unintentional acts such as physical, sexual, psychological, and financial abuse and neglect. Intimate partner violence is between spouses or nonmarital partners, threatened or actual physical or sexual violence or psychological/emotional abuse, coercive tactics, or both when there has been prior physical and/or sexual violence. Violence against an older adult can be perpetrated by someone other than the intimate partner. The other options are distractors for the question.

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse? Psychological Economic Physical Sexual

Psychological Threat to harm and intimidation are examples of psychological abuse. Economic abuse includes forging signatures. Physical abuse includes direct physical violence with harm inflicted. Sexual abuse includes fondling.

Which of the following is true about violence against women? Verbal attacks by a husband are not considered violence against a wife. Some experts purport that cultural attitudes influence violence. Between married couples, there is no behavior that meets the criteria for rape. Violence against women is a recent development in the United States.

Some experts purport that cultural attitudes influence violence. Culture, race, ethnicity, and the economy must be considered in the evaluation for suspected family violence. One needs to conduct a cultural assessment (using assessment guidelines) before attempting to understand a client's particular case of family violence, especially for members of families of a different ethnic origin from the primary ethnic background with which the nurse is familiar.

When describing an episode, the victim reports that she attempted to calm her partner down to keep things from escalating. This behavior reflects which phase of the cycle of violence? Battering Honeymoon Tension-building Reconciliation

Tension-building During the first phase, tension-building, the woman attempts to keep the situation from exploding based on her belief that the partner's anger is legitimately directed at her. The battering phase involves the explosion of violence. The honeymoon or reconciliation phase is manifested by a period of calm, loving, contrite behavior on the part of the batterer. The batterer may be genuinely sorry for the pain he caused.

The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family? A top nursing priority will be to legally remove the son from the home. The main focus of the nurse's actions should be on improving the elderly mother's self-esteem The nurse must allow the elderly mother to decide if she wants to leave the situation or not. Placement for the elderly woman in a nursing home within the community.

The nurse must allow the elderly mother to decide if she wants to leave the situation or no Removing children and older adults from their families or caregivers often is necessary to ensure immediate safety. If the home of an abused or neglected child or older adult cannot be made safe, the nurse must facilitate other professionals involved in placing the child or older adult in a foster or nursing home. Still, intervening in cases of elder abuse is not a clear-cut issue. When an older adult's decision making is not impaired (competence is the legal term), he or she must be allowed an appropriate degree of autonomy in deciding how to manage the problem even if he or she chooses to remain in the abusive situation. Forcing someone to do something against his or her wishes is itself a form of victimization and denies autonomous decision making.

Based on the nursing assessment, the nurse has formulated a nursing diagnosis of risk for post-trauma syndrome for an older adult. Which assessment data supports this nursing diagnosis? Select all that apply. The older adult rarely makes eye contact when interacting with the nurse. The older adult provides vague answers to questions without elaboration. The caregiver of a cognitively intact older adult answers the nurse's questions. The older adult's explanation is plausible and consistent with the extent of injury. The caregiver leaves the room to allow the older adult privacy with the nurse.

The older adult rarely makes eye contact when interacting with the nurse. The older adult provides vague answers to questions without elaboration. The caregiver of a cognitively intact older adult answers the nurse's questions. Risk factors for post-trauma syndrome include poor self-esteem and ineffective support system. An older adult who rarely makes eye contact and provides vague answers suggest low self-esteem. A caregiver of a cognitively intact older adult who answers the nurse's questions may be attempting to direct and monopolize the conversation with the nurse and divert attention from the older adult. A caregiver who allows private interaction between the older adult and the nurse suggests respect for the older adult and someone having nothing to hide. An explanation that is plausible and consistent with the extent of injury is not a red flag.

Which of the following would the nurse describe as a characteristic of the second phase of the cycle of violence? The batterer is contrite and attempts to apologize for the behavior. The physical battery is abrupt and unpredictable. Verbal assaults begin to escalate toward the victim. The victim accepts the anger as legitimately directed at her.

The physical battery is abrupt and unpredictable. During the second phase of the cycle of violence, the violence explodes and the batterer loses control physically and emotionally. During the honeymoon or third phase, the batterer is contrite and attempts to apologize for the behavior. During the first phase or tension-building phase, verbal or minor battery occurs and the woman often accepts her partner's building anger as legitimately directed toward her.

x A nurse has completed her assessment of a client whom she suspects is a victim of intimate partner violence. Which of the following should the nurse do at this point to verify that the data are reliable and accurate? Validate the data with the client Document the data following the health care facility's policy Examine her feelings, beliefs, and biases regarding violence Create a safe and confidential environment for interviewing the client

Validate the data with the client The nurse should validate any family violence data collected to verify that the data are reliable and accurate. She should also document the assessment data following the health care facility or agency policy, but this follows validation and is not done for the purpose of verifying that the data are reliable and accurate. Examining her feelings, beliefs, and biases and creating a safe and confidential environment are interventions the nurse should implement before beginning assessment, not after completing it.

The nurse prepares an educational program on bullying for the students who attend middle- and high-school. What types of bullying should the nurse include in this presentation? Select all that apply. Verbal Physical Financial Relational Damage to property

Verbal Physical Relational Damage to property The main four types of bullying include physical, verbal, relational, and damage to property. Financial is not a type of bullying.

Elder abuse can include nursing home admission. economic exploitation. using an elder day-care sitter. uncontested divorce.

economic exploitation. Economic abuse may be evidenced by preventing the victim from getting or keeping a job, controlling money and limiting access to funds, spending the victim's money, and controlling knowledge of family finances. Economic abuse, also known as financial abuse, is the improper exploitation of another person's personal assets, properties, or funds. A consequences of elder mistreatment includes the inability to pay for food or medication because of financial abuse.

The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should focus exclusively on the physical examination, as elder abuse is primarily physical in nature. make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication. ask to speak to Mr. Jenkins' son directly, to ask him candidly about the potential abuse. keep in mind that elder abuse is usually reported, indicating that Mr. Jenkins is not likely a victim.

make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication. A consequence of elder mistreatment is the inability to get food or medication because of neglect.

x When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should confine the interview to yes/no questions to keep the interview simple. remain calm and accepting in response to any information the client discloses. ask leading questions to convince the child to offer information. offer a reward to the child for answering difficult questions.

remain calm and accepting in response to any information the client discloses. Remember when asking questions to allow the client to answer completely. Do not interrupt the client. Convey a concerned and nonjudgmental attitude. Show appropriate empathy.

An emergency department nurse suspects a young client may be a victim of human trafficking when the nurse observes which of the following? Select all that apply. unable to state month or day not allowed to speak for themselves seems fearful and anxious appears malnourished has health insurance

unable to state month or day not allowed to speak for themselves seems fearful and anxious appears malnourished Signs and symptoms of human trafficking include, but are not limited to, not being free to leave the home (high security measures), being unpaid or paid very little, having no health insurance, owing a large debt that they are unable to pay off, appearing fearful and anxious, lacking health care, having few personal possessions, losing sense of time, being malnourished, and not being allowed to speak on their own behalf.