NCLEX Violence
A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her injuries is complete, and she is ready for discharge. What should the nurse do ensure the woman's safety and security prior to discharge? Select all that apply. 1. Determine if the client knows the location of the ex-boyfriend. 2. Ask if she plans to see the ex-boyfriend again. 3. Provide information on resources and a safety plan. 4. Ensure that she has a safe place to stay after discharge. 5. Obtain consent to send her emergency department records to her family health care provider.
1. Determine if the client knows the location of the ex-boyfriend. 2. Ask if she plans to see the ex-boyfriend again. 3. Provide information on resources and a safety plan. 4. Ensure that she has a safe place to stay after discharge. Explanation: The crucial interventions involve safety and support.
A 75-year-old woman was brought to the crisis center by her husband. The husband reports that his wife has been in shock and anxious since her purse was stolen outside of their home. The woman blames herself for being robbed, is worried about her stolen wallet and credit cards, and is afraid to go home. What nursing actions are indicated? Select all that apply. 1. Request a prescription for lorazepam to decrease her anxiety. 2. Encourage her to talk about the robbery and her feelings. 3. Discuss what changes at home would help her feel safe. 4. Investigate if she has physical injuries from the robbery. 5. Ask her what she thinks she could have done to prevent the robbery.
2. Encourage her to talk about the robbery and her feelings. 3. Discuss what changes at home would help her feel safe. 4. Investigate if she has physical injuries from the robbery. Explanation: After the impact of a crime, the client's most important needs are physical safety and emotional security.
A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the clients starts to cry and says, " He did not really mean to hurt me, but I hate for the kids to see this. I am so worried about them." What is the most crucial information for the nurse to determine? 1. The type and extent of abuse occurring in the family 2. The potential of immediate danger to the client and her children. 3. the resources available to the client 4. whether the client wants to be separated from her husband
2. The potential of immediate danger to the client and her children. Explanation: The safety of the client and her children is the most immediate concern. If there is immediate danger, action must be taken to protect them.
A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic(s)? Select all the apply. 1. assertiveness 2. self-blame 3. alcohol abuse 4. suicidal thoughts 5. guilt
2. self-blame 3. alcohol abuse 4. suicidal thoughts 5. guilt
In working with a rape victim, which intervention is most important? 1. continuing to encourage the client to report the rape to the legal authorities. 2. recommending that the client resume sexual relations with her partner as soon as possible. 3. periodically reminding the client that she did not deserve and did not cause the rape. 4. telling the client that the rapist will eventually be caught, put on trial, and jailed.
3. periodically reminding the client that she did not deserve and did not cause the rape. Explanation: Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape.
A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? 1. tight, impermeable boundaries 2. unbalanced power ratio 3. role stereotyping 4. dysfunctional feeling tone
3. role stereotyping Explanation: The traditional and rigid gender roles described by the client are examples of role stereotyping. The other listed answers are common in abusive families.
