violence and delegation

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The nurse provides care to a female client who presents with multiple gynecologic problems and a diagnosis of somatic symptom disorder (SSD). The client states to the nurse, "Intercourse is always so painful!" Which is the priority question when further assessing the topic of painful intercourse?

"Do you have a history of sexual abuse or trauma?"

The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply.

Confirming that the UAP has successfully passed this skill competency Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Confirming that the UAP has repeatedly completed similar tasks

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered healthcare worker (UHW)? Select all that apply.

Document intake and output in the electronic medical record. Reinforce tape over an abdominal incision. Provide report for the next shift.

A nurse has assessed a client in the hospital emergency department who was struck several times in the face by an intimate partner. As the client has their facial injuries assessed, they tell the nurse they do not want to return home. Which action should the nurse take?

Provide the client with a list of phone numbers for shelters

A pregnant client states, "My partner used to hit me before the pregnancy, but promised to stop now that I am pregnant. My partner loves our baby." Which action by the nurse is a priority?

Provide the client with information on resources for victims of intimate partner violence (IPV).

While doing the shift assessment on a 5-year-old boy, a nurse notices several bruises on his back and arms. The bruises are different colors and sizes. When she asks the child how he got them, he states, "I fell off of my bike." What should the nurse do next?

Talk with the child's parents when they arrive.

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply.

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse.

The nurse suspects that a client is a victim of intimate partner violence. What should the nurse consider when caring for this client? Select all that apply.

availability of support support can be accessed safely

the nurse is educating a group of student nurses on symptoms of sexually abused women. what symptoms will the nurse include in the teaching? SATA

chronic pelvic pain substance use disorder headaches social withdrawal

a nurse is conducting an in-service program for the staff of a local emergency department. the nurse is explain intimate parter violence and discussing the possible risk factors. which information would the nurse most likely include when discussing individual factors for becoming an abuser? SATA

low income serire for control experience of violence as a child

the nurse is preparing an education presentation on interfamilial sexual abuse. what family member will the nurse identify as being the primary sexual assailant?

male sibling, either biological or step brother

Which task(s) would a nurse choose to delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

taking a client's vital signs documenting a client's oral intake performing a blood glucose check assisting with I.V. insertion

a group of nursing students Is reviewing information about child abuse (child mistreatment and neglect and their effect on children. The students demonstrate understanding of the information when they identify which statements as accurate? Select all that apply.

the effects of child abuse (child mistreatment) are manifested in multiple ways. Vulnerability to abuse (mistreatment) depends on the child's age and sex.

A RN is delegating client care responsibilities to a licensed practical/vocational nurse (LPN/VN). Which nursing responsibilities would be appropriate to delegate to the LPN/VN? Select all that apply.

Changing the client's decubitus foot ulcer dressing. Reinforcing the teaching of proper diabetic diet. Obtain a bedside glucose specimen test at 1100.

Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply.

Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed.

The nurse is asked to provide information for a task force addressing child abuse (child mistreatment) in the community. Which prevention tactics are suggested? Select all that apply.

Develop and teach high school courses on parenting and normal child growth and development. Promote activities that encourage self-esteem in young adults. Role-model for caregivers various behaviors with children that are compassionate, loving, and caring. Educate those who were abused as children, and offer them professional help to break the pattern of violence. Help parents and caregivers find local support in their community.

A nurse is providing care to a victim of intimate partner violence. Applying the ABCDEs of care, place the actions in the order that reflects this framework from first to last. Use all options.

Reassure the victim that he or she is not alone. Express the belief that violence against women is not acceptable. Ensure confidentiality of information. Document the findings. Provide education about the cycle of violence. Ensure that the victim has resources and a plan of action for when he or she decides to leave.

The home health nurse is completing a screening for elder abuse during a client visit. Which findings would require action by the nurse? Select all that apply.

The client who is frequently scheduling appointments with their primary care provider. A client who reports having excessive sleepiness after their evening medications. A client who is less talkative recently and avoiding eye contact with the nurse.

The nurse working in a maternity clinic suspects that a client and her children are in a violent relationship. While waiting for test results, the nurse decides to teach the client about intimate partner violence. What would be the best rationale for the nurse's decision?

The nurse knows that children exposed to family violence are likely to be victims of abuse.

while obtaining a history from a women at a regularly scheduled physical, the nurse notices various bruising on the clients upper extremity. the client dismisses the bruising and changes the subject. which additional information about the woman as a victim would the nurse discuss with the HCP when relaying the physical assessment data? SATA

a dysfunction family system a low academic achievement a victim of childhood violence economic status

the ER nurse documents progress notes in the above note. when completing the documentation, which information would be included? SATA

diagram of site injuries description, including color and measurement, of injuries, objective findings from a thorough head to toe assessment

the school nurse os concerned that a young girl is being sexually abused. which assessment finding supports this concern? SATA

expresses fear about going home reports frequent UTIs demonstrates low self esteem

A nurse is conducting a program for a community group about violence and abuse. As part of the program, the nurse describes the characteristics of the typical abuser. Which characteristics would the nurse include? Select all that apply.

feelings of insecurity aggression to express inadequacies violence as a means of control antisocial behaviors

when screening a client about intimate partner violence, which question by the nurse would be most appropriate?

how does your partner treat you?


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