NUR410 maternity PREPu

While performing an assessment on a female client, the nurse notes signs of sexual assault. When questioned, the client states, "I am married, so I have not been raped or abused." What statement by the nurse is most appropriate?

"If you do not consent, it is still assault when you are married."

A client has just confided in the nurse about being slapped and kicked by the partner that morning. What is the best response by the nurse?

"It's very brave of you to tell me all this. Help is available if you choose it."

A nurse is a guest speaker for a local college campus group discussing violence and rape. After discussing rape with the group, the nurse determines that additional discussion is needed when the group states which information?

"Most rape victims tell someone about the rape."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"My partner tells me that I will be turned into child services for being a bad mother."

A nurse is working with a victim of intimate partner violence. The client has decided that she is going to leave the relationship. Which instructions by the nurse would be most appropriate? Select all that apply.

"Remember, it might take you several tries before you succeed." "Let's work on a safety plan so that it is ready for when you leave." "I can offer you choices, but you are the one who has to choose."

A client states "My spouse loves me. My spouse did not mean to hit me. My spouse felt so bad, I received flowers to show me how sorry my spouse was for hitting me. I know this will not happen again." How will the nurse respond?

"This is a common action of abusers. It does not mean you will not be hit again."

A client tells the nurse "My partner is going to stop drinking, so I know I won't be hit again." What is the nurse's best response?

"Violence is a learned behavior, not caused by alcohol."

A 10 weeks' gestation client states "My partner used to hit me before the pregnancy, but promised to stop now that I'm pregnant. My partner loves our baby." How will the nurse respond?

"You are at a higher risk for violence since you are pregnant."

A nurse is presenting a discussion on sexual violence at a local community college. When describing the incidence of sexual violence, the nurse would identify that a woman has which chance of experiencing a sexual assault in her lifetime?

1 in 5

A group of nurses are preparing a program about rape and sexual assault for a community health center. Which information would the nurses include as being most accurate? Select all that apply.

1. Few people falsely cry "rape." 2. A rape victim feels vulnerable and betrayed afterwards. 3. Medication and counseling can help a rape victim cope.

A nurse is assessing a victim of rape. Further assessment reveals that the client received rohypnol. The nurse understands that this drug can lead to memory loss for up to how many hours?

8

The nurse is caring for a client who is a victim of sexual violence. How can the nurse best support the necessary grieving process?

Actively listening to the client as he or she talks about the experience

The nurse is caring for a victim of intimate partner violence who needs emotional support. What nursing actions are appropriate for this client? Select all that apply.

Allow the client to make as many decisions as possible. Encourage the client to attend support groups. Teach strategies for problem-solving and stress management.

When beginning care for a victim of rape, the nurse asks the patient to "talk about what happened" to her. For which nursing diagnosis is the nurse using this approach?

Anxiety related to recent rape

A nurse is caring for a pregnant woman who has multiple bruises in varying stages across her body. Which is the priority nursing action?

Ask if anyone at home has hit or hurt her.

A nurse suspects that a client is experiencing intimate partner violence and uses a screening protocol to gather additional information from the client. When asking the client direct questions, which behavior by the nurse would be appropriate to elicit accurate information? Select all that apply.

Avoid the use of technical language. Wait patiently for the client to answer.

A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client?

Being nonjudgmental

To properly assist a victim of intimate partner violence, which action would be mostappropriate for the nurse to do?

Document the details.

A nurse is working in a community hospital situated in an area with a history of grievous assaults on women, including rape. The nurse discovers that most rape victims come to the hospital but leave without seeking medical treatment. Which intervention should the nurse perform to ensure that rape victims get legal and medical aid?

Ensure that the appropriate law enforcement agencies are apprised of the incident.

The nurse is caring for a client believed to be a victim of human trafficking. What action is mostimportant for the nurse to perform?

Gain the client's trust.

Which of the following is TRUE regarding intimate partner violence?

One in four women will be a victim of violence.

The nurse is caring for a client who is seeking care after being raped. What is the primaryreason the nurse does not leave the client alone during the emergency room stay?

Promotes the client's sense of safety

The nurse is assessing a client who is a victim of intimate partner violence and recognizes a belief that is common among victims of abuse. Which belief would the nurse most likely identify?

The client is inadequate in some way.

When implementing an intervention for a client experiencing intimate partner violence, what is the primary goal?

The client will regain a sense of control in life.

Which of the following scenarios should the nurse follow up on as a potential indication of intimate partner violence?

The partner of a pregnant woman attends each of her appointments. The partner is friendly and outgoing. Each time the nurse asks the client a question, the partner answers. While the partner speaks, the client looks at her lap.

A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of the injuries. The client also does not want the police to be informed about the incident even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case?

Use direct quotes and specific language.

A nurse is developing a plan of care for a victim of intimate partner violence. Which intervention would be least appropriate for the nurse to include?

assisting the client to project anger

A nurse is assigned to care for a client who was brought to the emergency department. The client was a victim of human trafficking. When providing care to this client, which intervention would have priority?

building trust

The nurse who counsels clients who suffer from intimate partner violence understands that abuse can come in which different forms? Select all that apply.

emotional abuse physical abuse financial abuse sexual abuse

Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)?

flashbacks

A nurse is assessing a rape survivor for posttraumatic stress disorder. The nurse asks the survivor, "Do you feel as though you are reliving the trauma?" The nurse is assessing for which effect of the trauma?

intrusive thoughts

When a pregnant client is victim of intimate partner violence during pregnancy, what complication is likely to occur after birth due to the abuse?

postpartum depression

A nurse is working with a victim of intimate partner violence. Which intervention would be most important for this client?

providing for the client's safety

A nurse is screening a client for intimate partner violence using indirect questions. Which question would the nurse most likely ask?

"Clients with your injuries are often abused. Is anything like this happening now?"

A client comes to the clinic for an evaluation. The client was a victim of rape about 5 months ago. The nurse is assessing the client for possible symptoms of posttraumatic stress disorder (PTSD). Which question would be most appropriate for the nurse to ask to determine if the client is experiencing avoidance reactions?

"Do you have trouble remembering exactly what happened?"

A victim of rape is prescribed emergency contraception. After teaching the client about this therapy, the nurse determines that the teaching was effective based on which client statement?

"It contains high doses of a typical birth control pill"

Which statement made by a male client who has a history of perpetrating intimate partner violence reflects a known factor that is characteristic of this behavior?

"My classmates always called me a bully."

After teaching a class about intimate partner violence to a group of young adults, the nurse determines that additional teaching is needed based on which statement by the group?

"People who are battered typically come from lower socioeconomic groups."

A new nurse in the emergency department is caring for a pregnant woman who was beaten by her partner. Which statement by the new nurse would require intervention from the supervising nurse?

"That woman must be doing something to get beaten like that."

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low birth weight infant