prep ch 9 Violence and Abuse

A nurse is caring for a pregnant woman who has multiple bruises in varying stages across her body. Which is the priority nursing action?

Ask if anyone at home has hit or hurt her.

A client at 36 weeks' gestation presents in the emergency department with a broken arm. The client states, "I fell while cooking dinner." During the assessment, the nurse notes no prenatal care for this pregnancy, as well as bruises in multiple stages of healing on the client's abdomen, arms, and chest. What action will the nurse perform next?

Ask the client how she acquired the bruises

A client comes to the clinic with a partner. The client has multiple bruises on the arm and neck. The nurse suspects that the client is a victim of intimate partner violence. Which action would the nurse do first?

Move the client to an area away from the partner.

Which type of elder mistreatment involves harm of self-worth?

emotional

An obviously pregnant woman appears for her first prenatal visit. She reports a headache and generalized abdominal pain which has persisted over the past couple months. Which question should the nurse prioritize after determining the client is approximately 24 weeks' gestation, appears nervous, and is reluctant to have a full physical assessment?

"Do you feel safe at home?"

A nurse is a guest speaker for a local college campus group discussing violence and rape. After discussing rape with the group, the nurse determines that additional discussion is needed when the group states which information?

"Most rape victims tell someone about the rape."

The nurse is assessing a client whose partner is present. The nurse notes the partner swears and yells, makes lavish promises, and threatens to hit the client. Which nursing intervention is a priority?

Ask the partner to leave the room.

A client has been admitted to the inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by a partner. During the admission process, which action is a priority for the nurse to complete?

Assess the client for suicide risk.

The nurse is interviewing a client who has experienced intimate partner violence. Which nursing intervention will likely be most effective in assuring the client that the interview will be kept confidential?

Assure the client agrees before any information can be released

A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client?

Being nonjudgmental

When initiating care for a client suspected of being a victim of human trafficking, what is the nurse's primary responsibility?

Building trust

A pregnant client with multiple bruises in various stages of healing comes to the clinic for treatment. She appears withdrawn and quiet when the nurse approaches her. Her partner accompanies her to the exam room and begins to answer for the client. There is minimal eye contact from the client to the nurse. Which action will the nurse complete next?

Have the client's partner leave the room.

The nurse is developing a plan of care for a client who is a victim of physical and mental abuse. Which action is most appropriate for the nurse to include in the plan?

Permit the client to participate in the care provided.

The nurse is caring for a client who is seeking care after being raped. What is the primaryreason the nurse does not leave the client alone during the emergency room stay?

Promotes the client's sense of safety

During a prenatal examination the nurse observes bruises on the client's arms and a black eye. When asked about the bruises, the client states, "It was an accident. My spouse just had a bad day at work, and I was late getting dinner prepared. But my spouse is being so kind now; my spouse brought me flowers yesterday. My spouse is looking for a new job, so it will not happen again." This client is in which phase of the cycle of violence?

The honeymoon phase

A nurse is working in a local community health care facility where many clients are victims of intimate partner violence. For which sign(s) will the nurse assess to determine if a client is a victim? Select all that apply.

mental health problems such as depression, anxiety, or substance abuse injuries on the face, head, and neck reported history of the injury inconsistent with the presenting problem

An 11-year-old boy was raised in a home where his father beat his mother on a regular basis. Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence?

They are at increased risk for being abused.

The nurse is caring for a client believed to be a victim of human trafficking. What action is mostimportant for the nurse to perform?

Gain the client's trust.

A newly pregnant 19-year-old woman grew up in an abusive home, and moved in with a 22-year-old man who is displeased with her cooking and housekeeping skills. He often becomes angry and physically abusive. The pregnant client has no diploma or job, no money for birth control, and her boyfriend demands sex at his leisure without use of condoms. What is the strongest risk factor for intimate partner violence during this pregnancy?

Prior abuse

During the assessment, a client states, "I need something to calm my nerves and help me with sleeping. My spouse will not let me look for a job, and when I need money, I am told I cannot have any since I do not work." Which action by the nurse is most appropriate at this time?

Provide the client with education on intimate partner violence.

The nurse is caring for a client who is a victim of sexual violence. How can the nurse bestsupport the necessary grieving process?

actively listening to the client as he or she talks about the experience

A nurse is preparing a presentation for a local community group about intimate partner violence. Which statement would be most appropriate for the nurse to include in the presentation?

Intimate partner violence in lesbian, gay, bisexual, transgender, queer (LGBTQ) relationships may go unreported for fear of harassment.

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"My partner tells me that I will be turned into child services for being a bad mother."

A new nurse in the emergency department is caring for a pregnant woman who was beaten by her partner. Which statement by the new nurse would require intervention from the supervising nurse?

"That woman must be doing something to get beaten like that."

The nurse who counsels clients who suffer from intimate partner violence (IPV) understands that IPV can come in which form(s) of abuse? Select all that apply.

emotional abuse, physical abuse, financial abuse, sexual abuse

A group of nursing students are preparing a talk on violence against women and how to prevent it. They want to list characteristics of perpetrators of intimate partner violence and should include which characteristics? Select all that apply.

substance and/or alcohol use disordernegative affect (hostility and depression)history of childhood abusecurrent unemploymenthistory of antisocial behavior

A nurse is describing the cycle of violence to a group at a community clinic. The nurse determines that the attendees have understood the information when they identify which phase as usually lasting the longest?

tension building

Nurses sometimes have difficulty assessing clients for intimate partner violence. Which screening protocol is most thorough when assessing for violence?

the SAVE model

The nurse is caring for a client who was raped 3 hours ago. Which intervention is a priority for the nurse to perform?

Administer prescribed emergency contraceptive pills.

The nurse is assessing a client who was a previous victim of rape. The nurse believes the client is in the integration and recovery phase following the rape. Which action will the nurse recommend to the client for continued recovery?

joining a rape survivor group

The nurse is talking to a client who is a survivor of intimate partner violence. The client states that the spouse has the characteristics of antisocial personality disorder. The client also informs the nurse that the spouse has an extensive criminal record. The nurse interprets this information and suspects that the client's spouse would demonstrate which behavior?

moderate to severe violence with people both within and outside the family

A client who is a rape survivor has appeared to cope very well. However, at a routine visit several months later, the client describes a new onset of nightmares and flashbacks. Which action by the nurse is most appropriate for this client?

Refer the client to a psychologist for psychotherapy treatment.