Abuse
The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client? A) Assist the client to devise a safety or escape plan. B) Encourage the client to take charge of the situation. C) Offer to contact outpatient services if the client promises not to return home after discharge. D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A Explanation: A client who has been victimized by a partner should have a safety plan. This has the highest priority as the client's life is in danger. The client has no control over the partner, and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging the client to take charge is too general a statement to be helpful; the client needs specific tools to develop a safety plan. It may not be safe and feasible for the client to leave the situation right away, and resources should not be withheld if a client is unable to promise not to return home.
Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain? A) Ultrasound B) X-ray C) MRI D) Blood test
Answer: A Explanation: An ultrasound or CT scan of the abdomen can check for abdominal or organ injuries. An MRI of the spine will show spinal injuries. X-rays can detect fractured bones. Blood tests may be used to detect sexually transmitted diseases.
A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate? A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem
Answer: A Explanation: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.
Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors? A) Social learning theory B) Psychopathology theory C) Neurobiology theory D) Environmental theory
Answer: A Explanation: Social learning theory explains that individuals learn violent tendencies through association with others and a reinforcement of the abusive behavior. Psychopathology theory suggests that some individuals who experience personality disorders and mental illnesses participate in family violence as a result of these illnesses. Neurobiology theory asserts that genetics plays a role in anger modulation and emotion control. Environmental theory is not related to the etiology of abuse.
An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply. A) Poor hygiene B) Dehydration C) Intracranial trauma D) Fecal impaction E) Dislocations
Answer: A, B, D, E Explanation: The nurse suspecting elder abuse would assess for clinical manifestations associated with elder abuse. Some of those clinical manifestations are constant hunger or malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it is a clinical manifestation of child abuse.
A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective? A) "Everyone knows what my problems are, and there is nothing I can do about it." B) "I am functioning fine now but I know that when problems come up again, I will ask for help." C) "My friends tell me that I have improved so this is a good time to stop." D) "It is so draining to deal with the same painful issues all of the time."
Answer: B Explanation: The client acknowledging that future problems will come up indicates that the client has gained insight into problems. The client's willingness to ask for help shows that the client is prepared to continue with counseling when new problems arise. Stating that the process is draining and painful suggests that little progress has been made and that the client is looking to avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of treatment on the statements of others places emphasis on others and not on self-evaluation.
A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply. A) Confusion B) Missing teeth C) Apprehension when other children cry D) Abrasions to the mouth, lips, and genitalia E) Dehydration
Answer: B, C, D Explanation: Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia; missing teeth; and apprehension when other children cry. Dehydration and confusion are manifestations of elder abuse.
A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take? A) Discuss what the nurse witnessed with the infant's mother. B) Discuss what the nurse witnessed with the other nurses. C) Report what the nurse witnessed and assessed to the authorities. D) Call security to remove the father from the room.
Answer: C Explanation: Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant's mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.
Which of the following is a common element of abuse experienced by the victim? A) Accidental injury B) Feelings of control C) Humiliation D) Manipulation
Answer: C Explanation: Common elements of abuse include humiliation, intimidation, and physical injury. Injury associated with abuse is not accidental. Feelings of control and use of manipulation tactics are related to the perpetrator, not the victim.
The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate? A) Contact adult protective services. B) Call the healthcare provider immediately. C) Assess the client's cultural traditions. D) Contact the client's family.
Answer: C Explanation: The most appropriate action for the nurse at this time is to assess the client's cultural traditions. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.
The nurse is providing care for a 2-year-old client. When assessing the client's risk for abuse, which factors increase this client's risk? Select all that apply. A) The child has bruises on the knees and shins. B) The child's parents are married. C) The child is less than 3 years old. D) The child is deaf. E) The child's parents are unemployed and receive medical assistance
Answer: C, D, E Explanation: Risk factors for child abuse include poverty, age less than 3 years, and child disability or condition that requires a great deal of care. Marriage of the parents and bruises on the knees and shins are not risk factors for abuse.