Chp 38: Care of Survivors of Abuse and Violence

16. An adolescent claims to have been physically abused by a parent. The adolescent's other parent angrily tells the nurse, "It's ridiculous for our child to accuse my spouse, who is a prominent doctor respected by the community." The nurse responds: a. "Do you believe that abuse does not exist in well-respected, professional families?" b. "I know that it is difficult to believe what your child is saying about your spouse, but abuse has occurred." c. "I know your spouse and I have never seen him be unkind or abusive to patients, but that is no proof of innocence." d. "Your spouse seems to have a very stressful, demanding practice. That can be a risk factor for losing one's temper when angry."

ANS: A The correct option effectively uses the therapeutic nursing communication of reflection. By reflecting back to the patient what she has said, the nurse assists the patient to view the statement in perspective. DIF: Cognitive Level: Application REF: Text Page: 738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

2. Which comment by the nurse would be most effective in teaching a patient about abusive behavior? a. "So when your husband says he needs other women because you aren't sexually satisfying his needs, do you believe what he is telling you is true?" b. "You say that your son has been pulling another child's hair and you are worried he's becoming violent and abusive like your brother?" c. "You say that you placed your son on an allowance but that you also want to regulate everything he spends and saves?" d. "I noticed that when your mother paid you a compliment about your new hairstyle, you seemed skeptical."

ANS: A The correct option is an illustration of how the nurse might help the patient to look at her husband's attempt to undermine her sexuality to inappropriately justify his infidelity. This is a form of sexual abuse. Questioning the son's behavior helps the patient to place fears (as yet unjustified by the patient's example) in perspective. The need to maintain control over the son's spending decisions describes a common parental error when first giving a child an allowance; the nurse will seek to clarify boundaries while remaining alert to the parent's attempts to maintain total control over all financial dealings of the child. Skepticism describes the patient's inability to acknowledge a parent's response as supportive. DIF: Cognitive Level: Application REF: Text Pages: 736-737 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. An individual who has been physically abused says, "When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money." Which comment by the nurse would be most therapeutic for this individual? a. "You feel your spouse was justified in the abuse because you overspent?" b. "Tell your spouse that if this happens again, I will report it to the police." c. "Your spouse abuses you when you overspend. So you think it will stop if you do not spend money?" d. "I can understand that you don't want to press charges, but your spouse needs help controlling anger."

ANS: A The correct option uses a therapeutic nursing communication to facilitate the victim of abuse to view the spouse's behavior in a more rational manner. Physical abuse is not excusable under any circumstances. DIF: Cognitive Level: Application REF: Text Page: 745 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

5. Which is the most appropriate initial action for a nurse when attempting to overcome personal negative attitudes about a patient who has a history of returning to an abusive spouse? a. Exploring own attitudes and values toward survivors of violence b. Identifying the dysfunctional behaviors exhibited by the violent family c. Concentrating on identifying any possible personal abusive relationships d. Attending seminars on the psychological impact of being the victim of abuse

ANS: A The first step toward effective intervention with survivors of family violence is the exploration of one's own attitude toward and knowledge about violence. DIF: Cognitive Level: Application REF: Text Pages: 737-738 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

12. When a nurse overhears the spouse of a patient threaten to "punch you in the face if you don't shut up" while sitting in the unit's dayroom, which action reflects the most immediate, therapeutic nursing intervention? a. Notify hospital security immediately that the situation exists. b. Tell the spouse, "Your presence is no longer permitted on the unit." c. Ask the patient if the spouse has ever engaged in abusive behavior. d. Tell the spouse, "The police will be called unless you leave immediately."

ANS: A The most therapeutic nursing intervention is to address the immediate threat of harm. By notifying hospital security the situation can be managed by individuals trained to do so effectively. DIF: Cognitive Level: Application REF: Text Page: 741 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

1. Which patient statements would be considered a potential risk factor for family-directed violence towards them? (Select all that apply.) a. "My parents certainly believed in not spoiling a child." b. "I'm angry that I had to get a part-time job to help buy food." c. "My family thinks I'm just a burden, but they'll be sorry that they treated me so badly." d. "When my spouse gets upset he tells me I'm no longer attractive because I've gained weight." e. "I work long hours to pay the bills and put food on the table but I can't seem to make my spouse happy."

ANS: A, C, D, E The correct options share a theme of fear, guilt, or failure. Anger would be a risk for abuse by the patient upon others. DIF: Cognitive Level: Analysis REF: Text Page: 748 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. Which assessment finding most clearly indicates that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault? The victim: a. is demanding and controlling when dealing with staff. b. appears to be confused, restless, and fearful when left alone. c. uses profanity to describe events surrounding the attack. d. experiences a panic attack on the anniversary of the attack.

ANS: B The acute stage, immediately after the attack, is characterized by extreme confusion, fear, disorganization, and restlessness. Although many victims will be visibly upset, some may mask these feelings and appear to be outwardly calm or subdued. Overly assertive behavior and the use of profanity may or may not reflect the patient's ability to cope with the events. The panic attack months after the event describes the second stage of sexual assault, which involves long-term reorganization. DIF: Cognitive Level: Application REF: Text Pages: 747-748 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

20. An Arab student new to an elementary school reports, "I don't want to go to gym class. It's never been a good class for me." Which factor would be of primary concern for a school nurse? a. The student's family's cultural beliefs regarding females interacting with males in public b. Complaints from others of "bullying" that occurs in gym class c. The student's problems adjusting to the new school environment d. A concern that the gym class is overcrowded and too competitive

ANS: B The child's complaint is vague. Although all the options are possible, the most common reason for a child to be resistant to a particular class relates to past experiences, such as having been a victim of bullying. This would be the most likely, and thus primary, concern. This option is the only one that reflects a safety issue. DIF: Cognitive Level: Analysis REF: Text Page: 741 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE

4. Which comment by the nurse would be most effective when using an empowerment model of intervention with an individual who has been abused? a. "You have left your spouse many times only to return. Please tell me how you view this last time as being different from all the times you left before." b. "Last time we talked, you thought your children would miss their father, but you now think they seem happier and almost relieved by your separation." c. "So you're having doubts and want to return to your husband even though you know that he broke your arm and caused your miscarriage?" d. "I support you returning to your spouse until you finally decide you have suffered enough.'"

ANS: B The correct option is a therapeutic reflection that helps the patient to sort out the fears that many victims of abuse have that their children will suffer without the other parent present. Commenting on a patient's history is sarcastic and nontherapeutic since it likely reflects the nurse's bias against the battered individual's ambivalence rather than viewing it as a normal part of the process that individuals who have been abused experience. DIF: Cognitive Level: Application REF: Text Page: 737 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19. A patient with swelling and a laceration above the right eye states, "I don't know what caused me to fall and cut my head on the door frame." The patient's spouse appears nervous but smiles when mentioning that the patient is "so clumsy at times." The nurse should give priority attention to which intervention when addressing this patient's needs? a. Directly asking the patient if spousal abuse is occurring or has ever occurred b. Completing a thorough assessment that includes a focus on signs of old injuries c. Interviewing the patient regarding the circumstances surrounding this suspicious fall d. Notifying security that there is a possibility that this patient is a victim of physical abuse

ANS: B The correct option reflects the nurse's appropriate attention to the determination of any physical indications that physical abuse may have occurred (Maslow's Hierarchy). The remaining options do not address this priority but rather focus on the emotional aspect of the situation. DIF: Cognitive Level: Application REF: Text Pages: 738-739 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment: Management of Care

6. A young, newly married adult says, "My spouse never lets me out of sight. I'm not allowed to do anything on my own, and I'm constantly accused of cheating." Which nursing comment is most therapeutic for this individual? a. "Have you discussed the behavior with your spouse?" b. "How does your spouse's behavior make you feel?" c. "Are there other examples of controlling behaviors on your spouse's part?" d. "Do you feel that your spouse has anything to be upset or suspicious about?"

ANS: B The most therapeutic communication is the one that facilitates the patient's expression of feelings. DIF: Cognitive Level: Application REF: Text Page: 748 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. A person currently in an abusive relationship tells a nurse, "My partner is really sorry for hitting me and wants to come back and be part of the family again." The nurse should provide which intervention? a. Share with the patient that abusers seldom voluntarily stop abusing. b. Encourage the patient to demand the abuser seek psychiatric help. c. Advise the patient to focus on minimizing the abuse if the relationship continues. d. Inform the partner that any physical abuse will certainly be reported to the police.

ANS: B There are community groups that help abusive individuals relearn coping mechanisms that are appropriate. This option is the only one that provides an appropriate, therapeutic intervention. DIF: Cognitive Level: Application REF: Text Page: 738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

3. What is the best initial approach for a nurse when managing the care of an individual with two children who works full-time and has been abused by a partner? a. Teach the individual how to avoid provoking the abuser. b. Assist the individual in filing a police report describing the abuse. c. Help the individual identify needs to best obtain the appropriate support. d. Facilitate the individual's move into a safe house located near the current workplace.

ANS: C In order to best provide support, the nurse must fully understand the patient's needs. This is done before support options can be determined. The other options are examples of interventions for needs that have not yet been determined. DIF: Cognitive Level: Application REF: Text Page: 736 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

18. Which statement best indicates use and abuse of power in a violent family situation? a. "I admit I was mad and yelling and swinging my fists in the air, but I wasn't trying to hit our child. I was letting off some steam. My spouse just overreacted." b. "When she found out I watched television instead of taking the kids to the park, she starting yelling about how I don't care about the kids. She has no right to get mad at me. I should have some time to myself." c. "I thought he would like this new recipe. I should have known better. I will not do that again. He was right. He works all day and should come home to a good meal that he can enjoy. It's not too much to ask of a wife." d. "All I did was tell him I need some money. I can't understand why he can't just give me what I need. I stay home and take care of his house and kids, and I have to almost beg before he gives me money to spend on myself."

ANS: C The correct option shows clear indication that the husband has power over his wife as she expresses agreement with his expectations and indicates she "should know better." The other options are examples of individuals feeling victimized and partners who are able to leave or participate in the situation without becoming victims. DIF: Cognitive Level: Application REF: Text Page: 736 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

1. Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive? a. Ask the patient to define "verbally abusive language." b. Provide the patient with examples of assertive communication. c. Identify the patient's verbal abuse in order to set standards for future dialogue. d. Remove privileges from the patient until communications show less aggression.

ANS: C This question asks that behaviors for intervention be prioritized. First, it is necessary to help the patient identify the problem and to set criteria for future communications. DIF: Cognitive Level: Application REF: Text Page: 739 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. An older adult patient exhibits bilateral bruising for the second time on both upper outer arms. When the nurse questions the patient about the bruising, the patient starts to cry and pleads, "Please don't say anything. It's not my daughter's fault. I just bruise easily." Which intervention reflects the best management of this situation? a. Calling the daughter to discuss both the bruising and her parent's reaction b. Reporting the elder abuse and informing the patient and the daughter of the action c. Notifying the patient's social worker of the bruising after a complete assessment has been completed d. Informing the patient and the daughter of the nurse's obligation to document the bruising and report the findings to protective services

ANS: D Although it is often difficult to differentiate elder abuse, bilateral bruising on the upper outer arms is a definitive sign. The nurse is responsible for reporting such findings and continuing vigilant observation for further signs of elder abuse and neglect. It is usually best to inform the family of your intention to report elder abuse with the expressed purpose of obtaining help for both; this makes protective services less threatening and preserves the nurse's therapeutic alliance. DIF: Cognitive Level: Application REF: Text Page: 742 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

17. Which patient is at greatest risk for physical abuse by a family member? a. A 15-year-old who lives with a single parent in an inner city apartment complex b. An 8-year-old who is mentally challenged and living with a foster family c. A 30-year-old adult who shares a home with a homosexual partner d. A 79-year-old with chronic depression who lives with a grandchild

ANS: D Among the aspects putting the 79-year-old patient at greatest risk for physical abuse by a family member are being elderly and experiencing a psychiatric illness. DIF: Cognitive Level: Analysis REF: Text Pages: 745-746 TOP: Nursing Process: Diagnosis|Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

11. An individual whose boyfriend raped her tells the nurse, "It's no use reporting it. Everyone knows I've been sexually intimate with him many times before." The nurse's initial response should be: a. "It's not your fault. He needs to get help controlling his anger." b. "You will need to talk to someone. Do you have a best friend to talk to?" c. "The police need to be aware that your boyfriend is willing to act this way when he's angry." d. "If you said 'no,' your boyfriend needs to respect your wishes. He needs help so this will never happen again."

ANS: D Contrary to some thinking, if a person says "no," the partner is responsible for respecting and complying with the request. Violence counseling is appropriate for both individuals in order to stress the importance of communication and respect between sexual partners. DIF: Cognitive Level: Application REF: Text Page: 747 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

7. Which behavior would the nurse expect in a person who commits psychic rape? The perpetrator: a. gives money to the victim after the rape. b. seduces the victim by providing wine, flowers, and music. c. threatens the victim to submit or else be severely beaten. d. always mentions including violent bondage in sexual activities.

ANS: D Psychic rape involves an assault on the victim's dignity and self-respect. Examples include verbal assault, street harassment, pornography in the media, and portrayals of violent sex. Giving money after rape describes an economic partnership. Gift giving describes a seduction rape. Threats describe a fear rape. DIF: Cognitive Level: Application REF: Text Page: 747 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

10. A nursing colleague says, "This patient was admitted claiming to have been raped by her boyfriend, but just look at the sexy clothes she's wearing." Which response reflects an understanding of the most likely source of the colleague's comment? a. "Have you ever cared for other sexual assault victims?" b. "Your sister was raped when she was in college, wasn't she?" c. "You have three unmarried brothers about the patient's age, don't you?" d. "Are you saying that wearing sexy clothes caused her to be sexually assaulted?"

ANS: D The correct option is the most professional response to a colleague who shows evidence of a bias. Although most nurses do not actually blame survivors for what has happened to them, research reveals that they are less tolerant of certain behaviors, such as going out late at night, not locking car doors, wearing provocative clothing, or not resisting the assault "enough." The first step in providing effective nursing care in this situation is exploring one's own attitudes toward victims of this crime. DIF: Cognitive Level: Analysis REF: Text Pages: 737-738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

14. Which comment best reflects the nurse's use of an empowerment model with an individual who has been abused? a. "Let me share with you my knowledge of what happens psychologically to individuals who have been abused." b. "I know that you feel that your partner will change, but the current research does not validate your thinking." c. "It's up to you to end the violence. You are the only one who can set limits on how your partner is allowed to treat you." d. "Let's consider what you believe your options are in terms of your relationship with your partner in light of the behavior toward you."

ANS: D The correct option uses an empowerment model by assuming mutuality in sharing and providing respect for what the survivor knows. DIF: Cognitive Level: Application REF: Text Pages: 737-738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity