NURS 3: Module 1: Victims of Violence

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. 1. "How would you describe your child's usual behavior at home?" 2. "These bruises seem excessive and suspicious. How did they happen?" 3. "What forms of discipline do you use with your child?" 4. "When you are stressed, what coping mechanisms do you use?" 5. "Who watches your child when you are at work?"

1,3,4,5 When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: Caregiver's perspective on the child's behavior (Option 1) Methods of discipline used with the child (Option 3) Routine caregivers for the child Caregiver stress, coping, and support systems (Option 4) Person or persons who care for the child when regular caregivers are away (Option 5) (Option 2) Use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse. Educational objective:When child abuse is suspected, the nurse should convey empathy and support when questioning a caregiver while maintaining a nonjudgmental, nonthreatening attitude. Open-ended questions are less threatening and provide more detailed responses.

A rape victim tells the emergency department nurse, I feel so dirty. Please let me take a shower before the doctor examines me. The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

ANS: BNo matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A persons lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

ANS: BOnly the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Womens shelter d. Vocational counseling

ANS: CBecause the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

A rape victim asks an emergency department nurse, Maybe I did something to cause this attack. Was it my fault? Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: DAlthough the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement? 1. Adult Protective Services 2. Social worker. 3. Medicare ombudsman 4. Dietitian.

1 Adult Protective Services should be called only if it is determined willful neglect or abuse of the client is occurring. 2 The nurse should arrange for the social worker to see the client and family to determine if some arrangements could be made to provide for the client's safety and for the client to be provided with nutritious meals while the adult children are at work. A long-term care facility or adult daycare may be needed. 3 The Medicare ombudsman is a person who represents a Medicare client in a long-term care facility. 4 The dietitian could see this client to determine eating preferences (74 inches = 6 foot 2 inches and 54.5 kg = 120 pounds), but the most appropriate intervention is safety. TEST-TAKING HINT: The question asks for the test taker to determine a priority inter- vention. The client is diagnosed with senile dementia and is being left alone for hours of the day. Safety is priority.

The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting? 1. Call the client's name to awaken him or her, but don't touch client. 2 Touch the client gently to let him or her know you are in the room. 3 Enter the room as quietly as possible to not disturb the client. 4 Do not allow the client to be awakened at all when sleeping.

1 Clients diagnosed with PTSD are easily startled and can react violently if awakened from sleep by being touched. 2 Touching the client can cause the client to become afraid, to believe himself or herself to be under attack, and to react violently. The nurse should not touch a sleeping client diagnosed with PTSD. 3If the client awakes with the nurse in the room, the client could become fearful and react to the fear. 4 There may be times when the nurse must awaken the client to determine if the client is physically stable. TEST-TAKING HINT: Option "4" can be eliminated because of the absolute statement "at all." Options "2" and "3" can be eliminated if the test taker thinks of how it feels to be startled when perceiving another person around him or her when the test taker was not aware of the other person's presence.

The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply. 1. The abuser calls the child a liar. 2. The abuser has a tendency toward violence. 3. The abuser exhibits a high self-esteem. 4. The abuser is unable to admit the need for help. 5. The abuser was spoiled as a child.

1 Frequently child abusers will deny the child's reports of abuse and say the child is a habitual liar. 2 Child abusers believe violence is an acceptable way to reduce tension. They tend to have a low tolerance for frustration and have poor impulse control. 3 Child abusers have a tendency toward feelings of helplessness and hopelessness. 4 Child abusers tend to blame the child for the abuse and not admit the problem is their own. 5 The child abuser may have been abused asa child, but there is no evidence of the child abuser being spoiled as a child. TEST-TAKING HINT: This is an alternative-type question. The test taker should examine each option carefully to determine if it could bea correct answer. Option "3" could be elimi- nated because of the adjective "high" and "5" could be eliminated because of the adjective "spoiled."

The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement? 1. Insist the woman press charges this time. 2. Treat the wounds and do nothing else. 3. Tell the woman her husband could kill her. 4. Give the woman the number of a women's shelter.

1 The nurse can encourage the client to press charges but has no right to insist. 2 The nurse should treat the wound and may find it frustrating the client will not press charges, but the nurse is obligated to provide the client information to help the client to get to a safe place. 3 The woman is more aware of this fact than the nurse. 4 The nurse should help the client to devise a plan for safety by giving the client the number of a safe house or a women's shelter. TEST-TAKING HINT: The test taker could eliminate option "3" based on common sense; the client lives in an abusive situation and realizes the abuser's potential more than the nurse. Option "2" could be eliminated by the phrase "do nothing else." Option "1" could be eliminated because of the principle of nurses empowering their clients, not overpowering them, which is what has been happening to the client already.

The nurse writes a nursing diagnosis of "risk for injury as a result of physical abuse by spouse" for a client. Which is an appropriate goal for this client? 1. The client will learn not to trust anyone. 2 The client will admit the abuse is happening and get help. 3 The client will discuss the nurse's suspicions with the spouse. 4 The client will choose to stay with the spouse.

1 The nurse should attempt to develop a relationship in which the client feels he or she can trust the nurse (males are abused by significant others too). 2 The first step in helping a client who has been abused is to get the client to admit the abuse is happening. 3 This could cause the abuse to escalate. 4 This is what the nurse is trying to get the client to avoid. TEST-TAKING HINT: Option "1" could be eliminated because it is the opposite of what the nurse tries to establish in a nurse-client relationship. Option "4" places the client in harm's way.

The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused? 1. There has not been any abuse to report. 2. The client is ashamed to admit being abused. 3. The client has Alzheimer's disease and can't remember. 4. The client has engaged in consensual sex.

1 This client has signs of ongoing abuse suchas multiple burns and contusions in different stages of healing. 2 Many times the elderly are ashamed to report abuse because they raised the abuser and feel responsible for their child becoming an abuser. The elder parent may feel financially dependent on the child or be afraid of being placed in a long-term care facility. Forty-seven states have Adult Protective Services (APS) created by the states to protect elder citizens. 3 There is no evidence provided in the stem of the client not being mentally competent, and there is evidence in the stem of physical abuse. This client is performing activities of daily living. 4 Consensual sex does not involve the physical abuse noted in the assessment. TEST-TAKING HINT: The test taker could eliminate options "1," "3," and "4" by examining the stem and noting the physical abuse occurring and by the fact the client is functioning by performing activities of daily living.

Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse? A Antonia, an adult child quits her job to move in and care for a parent with severe dementia. B Mr. Wright, an elderly man with severe heart disease resides in a personal care home and is visited frequently by his adult child. C Mrs. Hale, an elderly parent with limited mobility lives alone and receives help from several adult children. D Antoinette cares for her husband who is in early stages of Alzheimer's disease and has a network of available support persons.

A Antonia, an adult child quits her job to move in and care for a parent with severe dementia. In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parent. Caring for someone with severe dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse. The caregivers in option B are the staff working in the personal care home; the adult child does not have primary responsibility and, therefore, would not be a high risk for severe stress and abuse. In options C and D, the caregivers are receiving support and no one person has primary responsibility. This will be decrease the risk for severe caregiver stress.

The interventions common to treatment plans for survivors include which of the following? Select all that apply. A Establish trust and rapport. B Identify areas of control. C Remove the client from the home. D Support the client in the decisions he/she makes. E Encourage the client to pursue legal action.

A Establish trust and rapport. B Identify areas of control. D Support the client in the decisions he/she makes. Identifying areas of control empowers the client. Supporting the client in the decisions he/she makes empowers the client and enhances the client's current problem-solving ability. Establishing trust and rapport provides the client with an ally.

During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except: A conflictual relationships of parents. B inconsistent communication patterns. C rigid, authoritarian roles. D use of violence to establish control

A conflictual relationships of parents. There is no evidence in this situation that the parents are in conflict; in fact, the mother is describing that the child "needed to be disciplined." Often, in dysfunctional families, one child is singled out to be the victim and is the recipient of blame for problems. The inconsistent communication pattern is that the child received conflicting messages regarding preparation of food. The rigid authoritarian roles demonstrated by the mother's indicate that the child needs discipline from the father. This is an example of a rigid role expectation of the father as disciplinarian. Also, the father used violence to retain the position of control.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. Its so frustrating. Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. Tell me how you punish your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. d. Do you or your husband ever beat the children? e. Calling children stupid injures their self-esteem.

ANS: A, B, CAn interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesnt like me. He calls me stupid all the time. The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

ANS: A, B, CAnger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, CNeutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patients privacy may be compromised by the presence of family. The rape victims anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

ANS: A, C, E, F, GThe victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

A patient tells the nurse, My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

ANS: AAn abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the persons underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

ANS: ABecause the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: AShock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

An 11-year-old child says, My parents dont like me. They call me stupid and say I never do anything right, but it doesnt matter. Im too dumb to learn. Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

ANS: AThe child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the childs statements.

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3- year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the fathers unmarried sister who has come to visit for 2 weeks

ANS: AThe family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adults daughter, who becomes defensive and says, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

ANS: AThe patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

ANS: AThe patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, I will never be the same again. I cant face my friends. There is no sense of trying to go on. Select the nurses most important response. a. Are you thinking of suicide? b. It will take time, but you will feel the same as before. c. Your friends will understand when you tell them. d. You will be able to find meaning in this experience as time goes on.

ANS: AThe victims words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: AVictims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victims needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

What is a nurses legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the childs teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

ANS: B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, I want to go to school, but we cant afford a babysitter. It doesnt matter; Im too dumb to learn. What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

ANS: B child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinationse. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, EHIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

A nurse works with a person who was raped four years ago. This person says, It took a long time for me to recover from that horrible experience. Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

ANS: BA survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, You may not leave until you receive prophylactic treatment for sexually transmitted diseases. b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

ANS: BAll information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victims family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

ANS: BImmediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patients right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

ANS: BIn this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

ANS: BIntense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. She was very beautiful. b. I gave her what she wanted. c. I have issues with my mother. d. Ive been depressed for a long time.

ANS: BRape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

After treatment for a detached retina, a victim of intimate partner violence says, My partner only abuses me when intoxicated. Ive considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me. Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partners physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

ANS: BRisk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patients use of defense mechanisms.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects ones own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

ANS: BStrong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim

A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

ANS: BThe correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, You stay together, no matter what happens. Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

ANS: BThe only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.

An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patients adult child. This caregiver becomes defensive and says, It takes all my time and energy to care for my mother. Shes awake all night. I never get any sleep. Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mothers evening and night care. c. Support the caregiver to grieve the loss of the mothers ability to function. d. Teach the family how to give physical care more effectively and efficiently.

ANS: BThe patients child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, I cant believe Ive been raped. This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

ANS: BThe victims response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.

A rape victim tells the nurse, I should not have been out on the street alone. Which is the nurses most therapeutic response? a. Rape can happen anywhere. b. Blaming yourself only increases your anxiety and discomfort. c. You believe this would not have happened if you had not been alone? d. You are right. You should not have been alone on the street at night.

ANS: C A reflective communication technique is helpful. Looking at ones role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victims perceived role and interfere with further discussion.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.

ANS: CInjuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority question? a. Do you drink excessively? b. Did your partner beat you? c. How did this happen to you? d. What did you do to deserve this?

ANS: CObtaining the persons explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: CThe assessment of physical abuse is supported by the nurses observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victims comments.

ANS: CThe first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patients discharge? a. Patient states, I feel safe and entirely relaxed. b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

ANS: DAgreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurses interview, the employee says, My partner beat me, but it was because there are problems at work. What should the nurses next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

ANS: DDocumentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

ANS: DThe individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

A nurse working a rape telephone hotline should focus communication with callers to: a. arrange long-term counseling. b. serve as a sympathetic listener. c. obtain information to relay to the local police. d. explain immediate steps that a victim of rape should take.

ANS: DThe telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

Nurse Angela is working in the emergency department of Nurseslabs Medical Center. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? A Contact the appropriate legal services. B Ensure privacy for interviewing the victim away from the abuser. C Establish a rapport with the victim and the abuser. D Request the presence of a security guard

B Ensure privacy for interviewing the victim away from the abuser. Privacy, away from the abuser, is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser (especially if she decides to return to the abusive situation). In this situation, it is not the nurse's responsibility to make the decision to report the abuse. However, whenever injury is inflicted with a gun, knife, or other weapon, the nurse is obligated to report the abuse. Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish rapport with the abuser. The situation does not describe the abuser as currently violent or under the influence of substances; therefore requesting a security presence is inappropriate at this time.

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: DMonitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

The nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior? 1. The client is acting in a learned behavior pattern to get attention. 2 The client had to leave home because of promiscuous behavior. 3 The client has a psychiatric disorder called nymphomania. 4 The client is a prostitute and is trying to get customers.

1. Research suggests at least 67% of adolescents who are runaways or homeless have been abused in the home. This represents a learned behavior pattern getting the female adolescent attention. 2 One reason adolescents of both sexes run away from home is abuse in the home. 3 Nothing in the stem indicates the client was turned out of the home for any behavior. 4 This has the nurse medically diagnosing the client.This is a judgmental statement. TEST-TAKING HINT: The test taker should not read into the question or choose an option allowing the nurse to function outside the scope of practice. Option "2" is assuming facts not in the stem, and option "3" is asking the nurse to make a medical diagnosis.

The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby's father. Which intervention should the nurse implement first? 1. Complete a rape kit. 2. Notify Child Protective Services. 3. Call the parents to come to the school. 4. Arrange for the client to go to a free clinic.

1. The school nurse is not a Sexual Assault Nurse Examiner (SANE) nurse, and this child thinks she is pregnant, suggesting the abuse has been occurring for a period of time or at least in some months past. The child should be taken to a hospital for examination. 2 Child Protective Services should be notified to protect the child from further abuse and to initiate charges against the father. An intermediate school nurse cares for children in the 4th, 5th, 6th, or 7th grades, depending on the school district. 3 This action brings the abuser to the school. 4 Sending the child to a free clinic does not negate the nurse's responsibility to report suspected child abuse. TEST-TAKING HINT: All 50 states require the nurse to report suspected child abuse. Child Protective Services (CPS) is the advocate to notify. Nurses in a school clinic do not have the appropriate facilities to perform rape examinations. Option "4" does not address the abuse.

A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned? A Family violence affects every socioeconomic level. B Family violence is caused by drugs and alcohol abuse. C Family violence predominantly occurs in lower socioeconomic levels. D Family violence rarely occurs during pregnancy

A Family violence affects every socioeconomic level. Family violence occurs in all socioeconomic levels, races, religions, and cultural groups. Although violence is associated with substance abuse, it is not the singular cause. The statement that the family violence predominantly occurs in lower socioeconomic levels is false. Abuse often occurs during pregnancy; about 23% of all pregnant women seeking prenatal care are victims of abuse.

Thenurseisteachingaclassaboutrapeprevention to a group of women at a community center. Which information is not a myth about rape? 1. Women who are raped asked for it by dressing provocatively. 2 If a woman says no, it is a come on and she really does not mean it. 3 Rape is an attempt to exert power and control over the client. 4 All victims of sexual assault are women; men can't be raped.

.1 This is a myth believed by some people. Many individuals are raped, ranging in age from infants to the 90s, male and female, heterosexuals and homosexuals. No one asks to be raped. 2 If a person says he or she is not interested in any type of sexual activity, it means "no" and anything else is forced and it is rape. "No" means "no." It is considered rape if a prostitute says "no." 3 Rape is an act of violence motivated by the rapist desiring to overpower and control the victim. 4 Men and children can be victims of rape. Sexual arousal and orgasm do not imply consent; it may be a pathological response to stimulation. TEST-TAKING HINT: This is an "except" question, which means three (3) of the options will contain correct information. In this question, there are three (3) false statements about rape; this is a double-negative type of question.

Which question is an appropriate interview question for the nurse to use with clients involved in abuse? 1. "I know you are being abused. Can you tell me about it?" 2 "How much does your spouse drink before he hits you?" 3 "What did you do to cause your spouse to get mad?" 4 "Do you have a plan if your partner becomes abusive?"

1 Unless the nurse is being personally abused in the same manner the client is being abused and has seen the abuse taking place, the nurse cannot "know" the client is being abused. 2 Alcohol and drugs are implicated in the abuse of many clients, but not all abusers use alcohol or drugs. 3 This is agreeing with the abuser about the client causing the abuse. 4 This statement assesses the abused client's safety (or a plan for safety). TEST-TAKING HINT: Option "3" could be eliminated because it blames the victim. Option "1" can be eliminated because the nurse should not tell the client "I know" unless the nurse has proof or has been in the situation.

Mrs. Smith is admitted to the emergency department of Nurseslabs Medical Center with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband, Mr. Smith, who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? A Mrs. Smith's explanation is appropriate acceptance of her responsibility. B Mrs. Smith's explanation is an atypical reaction of an abused woman. C Mrs. Smith's explanation is evidence that the woman may be an abuser as well as a victim. D Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.

D Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser. Self-blame is a common psychological response for a woman who is a victim of abuse. In this situation, the message that violence occurred because the woman provoked the abuser is accepted and owned by the victim; however, the victim is not responsible for the violence. The statements in options 2 and 3 are not true.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

ANS: AThe diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

The emergency department nurse writes the problem of "ineffective coping" for a client who has been raped. Which intervention should the nurse implement? 1. Encourage the client to take the "morning- after" pill. 2 Allow the client to admit guilt for causing the rape. 3 Provide a list of rape crisis counselors. 4 Discuss reporting the case to the police.

1 This plan for the client to take RU 486, or the "morning-after" pill, prevents pregnancy from occurring, but it does not directly address coping skills. 2 The client may talk about "what if I had not done . . .," but the client is not guilty of causing the rape. 3 The client should be provided the phone number of a rape crisis counseling center or counselor to help the client deal with the psychological feelings of being raped. 4 This is a legal issue. TEST-TAKING HINT: The test taker should read the stem "ineffective coping" and eliminate the physiological problem in option "1" and the legal problem in option "4."

The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse's first action? 1. Call the security guard to escort the spouse away. 2 Discuss the injuries while the spouse is in the room. 3 Tell the spouse the police will want to talk to him. 4 Escort the client to the bathroom for a urine specimen.

1. This action could cause the spouse to become violent. The security personnel should not attempt to remove the spouse unless the client wishes them to do so. 2 Injuries resulting from spousal abuse should be discussed without the abuser present. 3 This may or may not be true. The client will have to prosecute, and many times the abused client will not do so. The client may feel responsible for the abuse or may fear for her children's lives or for her own, or there may be a financial hold the spouse has over the client. Battered woman syndrome has many facets. 4 By escorting the client to a bathroom for any reason, the nurse can get the client to a safe area out of the hearing of the spouse. This is the most innocuous way to get the client alone. TEST-TAKING HINT: When dealing with a vio- lent person, the nurse should use discretion to avoid the spouse erupting into violence directed against the nurse, client, or others in the emergency department.

During a prenatal assessment, the clinic nurse suspects that her client has been abused. Which of the following questions would be most appropriate? A "Are you being threatened or hurt by your partner?" B "Are you frightened of your partner?" C "Is something bothering you?" D "What happens when you and your partner argue?

A "Are you being threatened or hurt by your partner?" The use of simple, direct question, asked in an emphatic manner, is best to validate the presence of an abusive situation. The other questions are indirect and may not lead to the discussion of an abusive situation.

Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply. A Enuresis B Red and swollen labia and rectum C Vaginal tears D Injuries in different stages of healing E Cigarette burns F Lice infestation

A Enuresis B Red and swollen labia and rectum C Vaginal tears These are all indications that a female child has been the victim of sexual abuse. Options D, E, and F are signs of physical abuse of a child, not sexual abuse.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refusedf. Declined

ANS: B, C, FThe nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. Reported should be used instead of alleged. Penetration should be used instead of intercourse. Declined should be used instead of refused.

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the persons level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: DAnxiety is the result of a personal threat to the victims safety and security. In this case, the persons symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety allow the person to function at a higher level.

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, I cant talk about it. Nothing happened. I have to forget! What is the persons present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: DDisbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patients statements do not reflect somatic symptoms, repression, or projection.

Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? A Flexible role functioning between parents B History of the parent having been abused as a child C Single-parent home situation D Presence of parental mental illness

B History of the parent having been abused as a child One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy functioning, not abuse. Single-parent households and a history of mental illness are not established risk factors for child abuse by a parent.

A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the young children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation? A Delayed growth and development, related to performance expectations of child. B Anxiety (moderate), related to difficulty managing home situation. C Impaired parenting, related to role reversal of mother and child. D Social isolation, related to lack of extended family assistance.

C Impaired parenting, related to role reversal of mother and child. The role of a 12-year-old child in a family should not be that of a parent. In this situation, the child and mother have reversed roles. There is no evidence that the child has delayed growth or development, the mother in this situation is not demonstrating signs of anxiety, and there is no evidence in this situation that the family is socially isolated.

Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? A Contact the child's parents and ask about the child's injury. B Encourage the child to be truthful with her. C Question the teacher about the parent's behavior. D Report suspicion of abuse to the proper authorities.

D Report suspicion of abuse to the proper authorities. The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse. The parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency. Although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate. Questioning the teacher may or may not provide validation of the nurse's suspicions; regardless, this intervention does not ensure the child's safety, which is the priority.

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

ANS: AOlder adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

A child was abducted and raped. Which personal reaction by the nurse could interfere with the childs care? a. Anger b. Concern c. Empathy d. Compassion

ANS: AFeelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

When an emergency department nurse teaches a victim of the rape about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, DThese reactions are common to the long-term reorganization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

An adult tells the nurse, My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. Ive considered leaving but havent been able to bring myself to actually do it. Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: CThe honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

ANS: DRape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

Mariefer is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is:Assess the scope of the abuse problem. A Assess the scope of the abuse problem. B Analyze family dynamics. C Implement measures to ensure the victim's safety. D Teach appropriate coping skills

C Implement measures to ensure the victim's safety. The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety. The question is asking about implementing a specific nursing action, not assessing the problem or analyzing the family dynamics. Teaching coping skills is important; however, the priority action involves ensuring safety.

During a home visit to a family of three: a mother, a father, and their child, The mother tells the community nurse that the father (who is not present) has hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse? A The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening. B The nurse commends the mother's efforts and agrees to let her handle things. C The nurse commends the mother's efforts and also contacts protective services. D The nurse confronts the mother's failure to protect the child

C The nurse commends the mother's efforts and also contacts protective services. The nurse would validate and reinforce the mother's efforts to seek help; however, the nurse must also report the abuse to the appropriate protective services. The priority is to maintain the child's safety. The responses in options 1 and 2 are inappropriate; the nurse is failing to provide for the child's safety and is not following legal guidelines. In option 4, the nurse is alienating the mother, as well as failing to follow legal guidelines and ensure the child's safety.

Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? A The child is fearful of the caregiver and other adults. B The child has a lack of peer relationships. C The child has self-injurious behavior. D The child has interest in things of a sexual nature

D The child has interest in things of a sexual nature An 8-year-old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.

Sheila tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. A Help Sheila to develop a plan to ensure safety, including phone numbers for emergency help. B Help Sheila to get her boyfriend into an appropriate treatment program. C Communicate acceptance, avoiding any implication that Sheila is at fault for not leaving. D Help Sheila to explore available options, including shelters and legal protection. E Tell Sheila that the she should leave because things will not improve. F Reinforce concern for Sheila's safety and her right to be free of abuse.

F Reinforce concern for Sheila's safety and her right to be free of abuse. These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client's feeling responsible for the abuse. Advising the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.