Mental Health- PrepU Chapter 23

A nurse is screening a new client for intimate partner violence (IPV). What aspect of this woman's current circumstances is the most significant risk factor?

The client's family lives on less than $1,000 per month.

A client in an abusive relationship reports planning to leave the home the next time the partner is at work. Which suggestion would the nurse provide to the client?

"Be careful because the time of leaving is the greatest risk."

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

"Did you see that outfit that the client is wearing? What did they expect?"

The nurse can assess potential victims of domestic violence by asking which question?

"Has a past or current partner ever caused you to be afraid?"

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence?

"I don't know what else I can do to keep him from getting angry at me."

The nurse is discussing expectations of raising a child with a teenage client who is pregnant with their first child. The client's ex-partner will not be a participant in the parenting. Which client statement would be of greatest concern to the nurse?

"My child will love me, unlike my parents ever did."

A client is talking to the nurse about the partner's recent physical abuse toward the client stating, "I know my partner loves me and will probably take me out or buy me something to show how sorry they are." Which is the best response by the nurse?

"This is what is known as the honeymoon phase in the cycle of violence."

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?

"You have the right to be safe and respected."

The nurse is performing an assessment for a client suspected to have experienced domestic violence. Which statement(s) by the client support the suspicion that the client has experienced abuse? Select all that apply.

- "I am not allowed to have friends because they are nosy." - "My partner frequently drinks alcohol in large amounts." - "My parent was abusive to me when I was a child until I moved out."

The nurse is leading a community support group with female clients that have been abused. Which statement(s) by the group member indicates why some of the clients stay in the abusive home situation? Select all that apply.

- "I have no financial independence and would have nothing without them." - "I don't think very much of myself and feel this is the treatment I deserve." - "My spouse really does love me and just loses their temper when I do something stupid." - "If I tried to leave, my spouse would likely kill me and take my children."

A client present to the emergency department (ED) with a rib fracture and states, "I am so clumsy! My spouse always tells me that I need to be more careful." The client's spouse is asked to leave the exam room for the assessment. When the spouse is gone the client states, "My spouse doesn't mean to hurt me. I usually push too hard, and they just loses control!" Which response by the nurse is appropriate? Select all that apply.

- "It is not your fault." - "I am glad that you told me." - "I am really sorry this happened to you."

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.

- A 6-year-old is being seen for the 5th time for a urinary tract infection - A baby with contrecoup injuries to the brain - A 3-month-old with a fractured femur

Which characteristics are found in violent families? Select all that apply.

- Abuse of power and control - Alcohol use disorder - Social isolation

Which are forms of psychological abuse? Select all that apply.

- Insulting - Humiliating - isolating a person from family

A pregnant woman comes to the clinic for a routine visit. Upon examination the nurse notices bruises on the client's upper arms and neck. The client reports that her husband has been abusive to her. The nurse is concerned because abuse during pregnancy can lead to which condition? Select all that apply.

- Low birth weight - Low maternal weight gain - Infections - Anemia - Miscarriage

The nurse conducts a wellness visit for a pediatric client. Which findings could indicate an increased risk for child abuse and the potential need for an additional assessment? Select all that apply.

- The child is diagnosed with a developmental delay. - The child has bruises in various degrees of healing on the buttock and upper legs.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply.

- The client is embarrassed of the assault. - They have a fear of being blamed for the incident. - The perpetrator may use coercion or threats to control the victim.

The nurse is teaching a victim of intimate partner violence how to create a safety plan. Which should be included when the nurse is assiting the client in devising an escape? Select all that apply.

- prepare and hide an escape bag - map the house for an escape route - recognize signs of the perpetrator losing control - configure a list telephone numbers needed in case of emergency

A school nurse is educating a group of adolescents about rape and sexual assault. The nurse evaluates the students' understanding when they report which statement as correct regarding the incidence of rape?

The highest incidence of rape occurs in adolescents and young adult female clients.

Approximately what percentage of women rape victims are raped by someone they know?

65%

The nurse is assessing an elderly client in the emergency department. There are many bruises present on the client's body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next?

Ask the client when and how the bruises occurred

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Accurately and thoroughly document the findings and report to the appropriate authorities.

The nurse assesses a client who comes to the emergency room for vaginal bleeding and swelling of the vagina. The client reports they had sexual intercourse with their partner the previous night and states, "It was consensual, but sometimes they are rough." The client begins to cry and looks away. Which is the priority action by the nurse?

Ask the client if they feel safe in their environment.

A nurse is seeing a pre-school child who is brought to a pediatric clinic by a parent with concerns about toilet training. The nurse notes the child has multiple bruises of various ages on the arms, trunk, and legs. Which is the priority intervention by the nurse?

Document the findings and notify child protective services.

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect?

Stalking

A client has been admitted to the medical unit from the emergency department after experiencing a violent assault. What action should the nurse prioritize when planning this client's care?

Establishing rapport with the client

A young client telephones the emergency department and loudly tells the nurse, "I've been raped! Please help me!" Which is the priority for the nurse to determine?

If the client was in a safe place, the client's condition, and if transportation is available

A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a person would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which approach?

Keeping focused on the client's feelings about the client's life situation

A nurse is assessing a survivor of abuse. Which assessment would be most important for the nurse to complete first?

Lethality assessment

Which statement requires additional education regarding the truth about rape?

Rape is a crime of passion.

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client?

Rape-trauma syndrome

A female college student comes to the counseling center and tells the nurse she is afraid of her boyfriend. She states, "He is so jealous and overprotective; he wants to know where I am and who I'm with every minute." The nurse recognizes this as which of the following?

The tension-building phase of the violence cycle

A nurse provides care to individuals who have been sexually assaulted during their childhood and is formulating data for a presentation to the staff. Which characteristic is most commonly noted on assessment of such clients and should be included in the presentation?

Unusually aggressive

The cycle of violence or abuse is a reason often cited for why women have difficulty leaving abusive relationships. Which of the following is an inaccurate picture of the cycle of abuse that occurs over time?

Violent episodes are less frequent

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement?

abandonment

The nurse provides care to a 4-month-old infant who presents to the emergency department (ED) with the parents at the advice of the pediatrician due to poor feeding and potential dehydration. Which finding noted by the nurse during the physical examination indicates the need to assess for child abuse?

ecchymosis to the arms

The nurse provides care for a client who reports intimate partner violence (IPV). Which intervention does the nurse include in the client's plan of care to address safety planning?

educating about perpetrator about behaviors indicative of losing control

The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse?

neglect

A client arrives for a follow-up appointment to receive the results of laboratory tests. For which result would the nurse take the opportunity to assess the client for intimate partner violence (IPV)?

positive pregnancy test

A client who experienced intimate partner violence (IPV) has had a complete physical examination with collecting of specimens. Which area would the nurse make a priority next?

safety