HESI- Rosa Iminez
Before Rosa is transferred, which of the following are appropriate? SATA A. Ask Rosa if she wants to see her husband B. Assess for any suicidal tendency C. Document specifically and objectively all of the information you have concerning Rosa's physical and emotional status D. Assess the severity of Rosa's mistrust of men E. Advise Rosa to to legally prosecute her husband
A,B,C Ask Rosa if she wants to see her husband Rosa should be given the opportunity to see Miguel if she wishes. She may have her own reasons for wanting or not wanting to see him. These reasons need to be respected. If Rosa decides to see Miguel, it would be helpful to talk with her beforehand about coping with the stress of seeing him. Assess Rosa for any suicidal tendency The seriousness of Rosa's suicidal comment should be determined before she is transferred. Document specifically and objectively all of the information you have concerning Rosa's physical and emotional status Documentation is always important. In an alleged rape situation, documentation is critically important in assuring adequate evidence for a fair trial, should one occur. Location of specific injuries, size and other characteristics of the injuries, Rosa's description of how they occurred, objective descriptions of her affect and behaviors during the examinations, laboratory tests that were completed, medications that were given to Rosa, and how Rosa's injuries were treated are some of the items that need to be recorded.
Miguel finally agrees to talk with you, and allows Rosa to be seen alone. Which of the following questions/statements could be appropriately used in your interview with Miguel? SATA a. "Tell me what it is like for you with Rosa being pregnant." b. "What do you like about having a child?" c. "Has Rosa's pregnancy caused any problems?" d. "What does it mean for you to be having a child?" e. "How do you usually deal with change?" f."How do you hit your wife? g. "Who do you consider to be in charge in your family?"
A,B,C,D,E,G "Tell me what it is like for you with Rosa being pregnant." This open-ended statement would be useful in allowing Miguel to talk about whatever he wants. This approach would help build trust and not challenge any need for control. It would also convey respect and an attitude of real concern. "What do you like about having a child?" Trying to determine Miguel's positive attitudes and feelings about having a child is important. This information might be useful in future meetings to help improve Miguel's self-esteem and employ his help in changing the situation if abuse exists. "Has Rosa's pregnancy caused any problems?" It is important to determine any problems Miguel is having as a result of Rosa's pregnancy. Help can be offered to Miguel to deal with problems. Although it is unlikely that Miguel will reveal any problems, an effort should be made to identify any that may exist. "What does it mean for you to be having a child?" This broad, open-ended question would allow Miguel to talk about his thoughts and feelings related to the pregnancy, children, and being a father. It would allow Miguel to steer the conversation in whatever direction he might choose and not challenge any need for control. "How do you usually deal with change?" This approach would be useful in determining how Miguel usually copes with stress and change. Miguel may have healthy coping responses that are not currently being used. "Who do you consider to be in charge in your family?" This question would be important in determining whether or not Miguel perceives himself in charge of Rosa. If this is so, he may feel entitled to discipline her by striking her. Family roles are often culturally-based and should be accepted, as long as they do not include a right to abuse.
After initial triage, what nursing actions do you expect the Emergency Department (ED) nurse to appropriately take with Rosa? SATA A. Take Rosa to a quiet, private room B. Let Rosa know she is safe C. Follow protocols for collecting evidence of rape D. Make a variety of people interview and examine Rosa (laboratory technician, MD, social worker, crisis counselor) E. Use a crisp, distancing, professional style to probe into Rosa's situation F. Help Rosa bathe and change clothes after her examinations
A,B,C,F Take Rosa to a quiet, private room Rosa needs a private area where she can talk and cry freely. A private room will minimize stimulation from other activity in the Emergency Department (ED). Let Rosa know she is safe It is very likely that Rosa remains scared and feels out of control. Telling her verbally that she is safe will help her to "hear" and internalize that she IS safe. Follow protocols for collecting evidence of rape Should Rosa decide to press rape charges, evidence would be important. Agency policies for collecting evidence should be followed. Help Rosa bathe and change clothes after her examinations Rosa may feel dirty and violated, and her current physical state may be a reminder of what occurred. She needs to bathe and change clothes as soon as possible. Cleaning up can be done in stages. For example, mouth care can be accomplished after the oral exam is done and oral swabbings are taken.
You are a nursing case manager on the county mental health outreach team. The local Mental Health Center has a treatment and referral contract for behavioral services with local healthcare practitioners.A Health Insurance Portability and Accountability Act (HIPAA) business agreement has been signed between the parties, which allows for exchange of need-to-know information and appropriate planning and treatment of patients to occur. A nurse midwife affiliated with a local obstetrician's office calls and reports that Mrs. Iminez (Rosa) has been in for prenatal care over the last several months. At Rosa's prenatal visit two weeks ago, the midwife noted multiple bruises, and belt marks on her chest, back, and abdomen.Rosa said that she 'bumped into a door,' and would not comment any further. At today's prenatal visit, new bruises and what appear to be cigarette burns were noted. Rosa is to return the following day with her husband for a prescheduled class.Fearing intimate partner violence (IPV), you arrange to be present when Rosa and her husband attend the class, and plan to speak with them.
Abused persons may also have symptoms of stress. These can include difficulty sleeping, recurring nightmares, diminished appetite and poor eating, memory deficits, and even out-of-body experiences. Intimate partner violence often involves a repeated pattern of tension-building, acute battering, and loving reconciliation. This is known as the cycle of violence.The tension-building phase includes verbal abuse and minor incidents. The acute battering phase includes the outbreak of serious violence. The loving reconciliation (honeymoon) phase is marked by remorse and promises to reform. As the cycle progresses, the first two phases predominate. The following day, prior to your meeting Rosa and her husband, you review Rosa's medical record, including the family and social history originally provided.Both Rosa and her husband are United States citizens whose great-grandparents came to North America from Cuba to establish a better life. Rosa is an elementary school teacher. Miguel owns a department store chain. You are introduced to Rosa and Miguel when they arrive.You notice that Miguel is very protective of Rosa, insists on staying with her, and often answers for her. Rosa looks to Miguel before she speaks, and keeps her eyes on him or looks at the floor when she speaks. After Rosa and Miguel share information about their health and family, you mention concern about Rosa's bruises.Miguel states "Rosa is very clumsy, especially since she became pregnant." You ask Miguel to stay and speak with you while Rosa is examined by the midwife.Miguel becomes angry and initially refuses to speak with you alone, or have Rosa be seen alone without him present.
You know that the abusive person often seeks relief from anxiety and tension by becoming angry, aggressive, and physically harmful to those around him. Not only are anxiety and frustration relieved ..... but the abuser may temporarily feel more powerful and in control through his aggressive acts. The abusive person generally has a deflated self-concept ..... aggression is a means to dominate the family and help the abuser feel superior, thereby unconsciously overriding his poor self-image. Often, the abusive person was exposed to abuse while growing up.
As you talk with Miguel, he remains superficial and social in his words and affect. Although generally polite and smiling, at times he is condescending, conveying an attitude that he doesn't have to answer your questions. Miguel assures you that there is no need for concern. He and Rosa are doing fine. Rosa's pregnancy is not causing any unusual tension between them.Miguel is proud that he will be a father and hopes he will have a son. Furthermore, he is a successful businessman with many friends. He knows how to deal with problems ..... his reputation depends on it. And, "NO", he does not drink. He needs a clear head to maintain his business.And, "NO AGAIN," he does not use any drugs, nor has he had any head injuries, episodes of depression, or other medical problems. After sarcastically thanking you for the inquiries into his health, Miguel asks, "Who is the patient here anyway? Me or my wife?"
Which approach is best to use to persuade Miguel to speak with you privately? a. It's agency policy that each spouse be interviewed separately at periodic times throughout a pregnancy. b. Pregnancy can add stress to any family. I am concerned about you and your needs. c. We suspect that your wife is being abused and I want to talk to you about it. d. Your wife canceled her appointment last week. I would like to hear your explanation.
B, This approach is best at this time. It lets Miguel know that you have concerns for his well-being as well as Rosa's. Establishing rapport is the first step in any therapeutic relationship.
Unable to verify that Miguel has abused Rosa, the midwife decided that it was a priority that Rosa know how to get help if she needed it. Which of the following information is most important for Rosa at this time? A. The names of several psychiatric clinical nurse specialists who provide in depth insight-oriented psychotherapy B. The telephone numbers of crisis hot line, battered women's shelter, legal protection agency, and the police C. A brochure about infant and toddler growth and development D. A brochure about the effects of drug use on a developing fetus
B The telephone numbers of a crisis hot line, battered women's shelter, legal protection agency, and the police Up to this point, Rosa may not have had access to emergency contact information. Having this information may be an encouragement to seek help if 'accidents' happen again. It is critical that Rosa know who to call in a crisis. It is important that Rosa sees these sources of support as alternatives to her present situation.
After listening to Miguel, you attempt to therapeutically respond in an empathic and caring manner when you say: A. So! Women are all the same, are they? I'm not like other women! B. I imagine you feel powerful and strong when you are able to get what you want that way. C. I imagine you want to show other women who's boss, too.
B "I imagine you feel powerful and strong when you are able to get what you want that way." This response would attempt to validate what you heard Miguel say and convey your interest in understanding him. It would be empathic and encourage further communication.
It is important for you to be aware of issues and facts concerning IPV. Which of the following accurately reflects current understanding of IPV. SATA a. IPV is usually limited to physical assault, and rarely encompasses emotional of sexual abuse b. Pregnant women are especially vulnerable to IPV. c. Victims of IPV may feel guilty and deny fear related to the situation d. Victims of IPV are at high risk for suicide. e. Personal discomfort of HCP with IPV can interfere with accurate assessment and intervention.
B,C,D,E Pregnant women are especially vulnerable to intimate partner violence Pregnant women are especially vulnerable to intimate partner violence. Abuse often begins in pregnancy, placing the unborn child at risk for severe fetal complications. Victims of intimate partner violence may feel guilty and deny fear related to the situation Victims of abuse exhibit characteristics of low self-esteem, self-blame, and guilt, and may deny the terror or anger they feel with regard to their situation. Denial is the most common coping mechanism of women who are victims of intimate partner violence. By using denial, a woman protects herself from the pain of a multitude of potentially-overwhelming emotions. Victims of intimate partner violence are at high risk for suicide Suicide attempts are often associated with intimate partner violence. It is important to assess for suicidal ideation and potential when working with possible victims of intimate partner violence. Victims may also use alcohol and/or drugs to escape from a situation that seems intolerable and unsolvable. Personal discomfort of health care providers with intimate partner violence can interfere with accurate assessment and intervention Health care providers are often uncomfortable dealing with intimate partner violence. Denial that violence is occurring may be used to distance themselves from the situation. It is important that healthcare providers take time to self-evaluate feelings about intimate partner violence and any feelings of negativity or horror that might interfere with appropriate assessment and nursing care.
Which response to Rosa is most therapeutic? A. That's all right. You're not weak or helpless. B. You had a right to not have sex with him. C. Right now it feels overwhelming. We can take things one step at a time D. Die? You want to die? You have so much to live for with the baby on its way
C "Right now it feels overwhelming. We can take things one step at a time." Rosa is saying that she feels trapped and overwhelmed. Rosa's communication reflects many conflicting feelings and thoughts and an inability to make decisions. Helping Rosa see that her problems can be broken down into manageable, solvable pieces would be therapeutic.
Which one of the following nursing diagnoses accurately reflects Rosa's situation at this time? A. Impaired skin integrity related to self-inflicted wounds B. Situational low self-esteem r/t possible abuse by husband C. Possible disabled family coping r/t to stresses of marriage and pregnancy D. Risk for violence r/t presence of wounds
C Possible Disabled Family Coping related to stresses of marriage and pregnancy While you suspect that the Iminez's have a dysfunctional relationship, you still do not know this for sure. This 'possible' nursing diagnosis is appropriate.
Although you suspect that Miguel is abusive to Rosa, you contemplate the pros and cons of confrontation and decide not to confront him at this time. The major reason for not confronting Miguel is that he might: a. sue you, the obstetrician, and the community mental health center for libel b. become aggressive with you c. decide not to continue a relationship with you or be open to receiving help d. prevent Rosa from receiving the care she needs
D Your primary concern is Rosa's care. If you confronted Miguel, you would risk making him angry. He might retaliate by not allowing Rosa to have prenatal care. Furthermore, he might continue and even escalate his abuse.
You decide to end the interview with Miguel. Which statement to Miguel would most likely allow for a continued relationship with Miguel? a. " I see there is no cause for concern. Thank you for your time." b. "Rosa is definitely the patient here. I am sorry to have bothered you and hope I have not offended you." c. "There is something highly suspicious here. I am going to have to investigate further." d. "May I call on you again for further information? And, if you have questions or concerns, please call me. Here is my card.
D, "May I call on you again for further information? And, if you have questions or concerns, please call me. Here is my card." This statement is best. It is direct, neutral in emotional tone, non-confrontive, and honestly expresses a desire for continued contact. It offers help to Miguel and at the same time asks for his help.
While you where with Miguel, the midwife talked with Rosa. To help Rosa feel safe and comfortable, the midwife: SATA a. Accused Rosa of protecting her husband by not telling the truth b. Implied that Rosa was weak and likely being abused c. Probed with direct questions about Rosa receiving her wounds d. Conveyed respect and empathy for Rosa's position as an adult woman e. Was patient and waited out silences to give Rosa time to recollect her courage and thoughts f. Acknowledged that woman are sometimes injured by people close to them g. Reacted with anger and disapproval when Rosa spoke about bumping into a door
D,E,F conveyed respect and empathy for Rosa's position as an adult woman Respect and empathy are generally comforting and, used by the midwife, helped Rosa to feel safe. The midwife showed respect and empathy for Rosa through her words, behaviors, and attitudes. was patient and waited out silences to give Rosa time to collect her courage and thoughts Often, it takes time for someone who is abused to find the courage to admit abuse, decide about what she wants to say, how much to reveal, and how she wants to say it. In allowing Rosa time, the midwife demonstrated respect for her. acknowledged that women are sometimes injured by people close to them It is important to acknowledge the possibility of abuse. This acknowledgment can be done in a gentle, caring, non-probing manner. The midwife successfully introduced the topic of abuse in general terms as a useful first step with Rosa.
Symptoms of the abused person
difficulty sleeping, recurring nightmares, diminished appetite and poor eating, memory deficits, and even out-of-body experiences
Warning signs before violence occurs:
increased possessiveness and jealousy on the part of the abuser, demeaning comments toward the victim, and efforts to isolate the victim from friends and family