Ch 10 Health Assessment Prep U

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence? "I will assess pregnant clients who come to the clinic." "I will assess a client for abuse and violence only when they present with bruises or a broken limb." "It is not necessary to assess every client. Some clients get offended when you ask them those questions." "I will assess a client for abuse and violence with every client encounter."

"I will assess a client for abuse and violence with every client encounter."

The Healthy People 2020 objectives where distributed during a staff meeting. Which objectives relate to the prevention of violence? Select all that apply. Substance abuse Bullying Homicides Firearm injuries Fatal and nonfatal assaults

Bullying Homicides Firearm injuries Fatal and nonfatal assaults

The nurse is concerned that an older community member is being abused by an adult son however will not report the abuse or seek help. What could be a reason for this older adult to refrain from reporting the abuse? The older adult loves the son Fear of being institutionalized The abuse is not that bad The son provides companionship

Fear of being institutionalized

The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse? The spouse is jealous The spouse was trying to get the client's attention The client was sharing too much information with the other person The client is not permitted to have contact with others

The client is not permitted to have contact with others

When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider? To have a close personal friend or relative in the room during the interview The client's physical and emotional safety That the interview be done in public To have social services present

The client's physical and emotional safety

The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family? A top nursing priority will be to legally remove the son from the home. The main focus of the nurse's actions should be on improving the elderly mother's self-esteem The nurse must allow the elderly mother to decide if she wants to leave the situation or not. Placement for the elderly woman in a nursing home within the community.

The nurse must allow the elderly mother to decide if she wants to leave the situation or not.

Elder abuse can include using an elder day-care sitter. economic exploitation. nursing home admission. uncontested divorce.

economic exploitation. (The six types of elder abuse are physical (injury by hitting, kicking, pushing, slapping, burning, and so on), sexual (unconsented sexual act), emotional (harm of self-worth or emotional well-being), neglect (failure to meet the older adult's basic needs of shelter, food, and so on), abandonment (leaving an older adult alone and no longer providing care), and financial (illegally misusing money, property, or assets).)

The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should keep in mind that elder abuse is usually reported, indicating that Mr. Jenkins is not likely a victim. ask to speak to Mr. Jenkins' son directly, to ask him candidly about the potential abuse. make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication. focus exclusively on the physical examination, as elder abuse is primarily physical in nature.

make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication.

A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries? "You need to tell me who hurt you or I will have to call social services." "Injuries like yours could have been caused by someone hurting you. Did someone hurt you?" "Why don't you tell someone you were hurt by your mother?" "I know your mother hurt you. Am I right?"

"Injuries like yours could have been caused by someone hurting you. Did someone hurt you?"

Emergency medical services bring a client to the hospital after finding her unconscious in an alley. When the client regains consciousness, responses to assessment questions indicate to the nurse that the client may have been abused but that the client appears uncomfortable discussing the events. What open-ended question might be helpful when assessing abuse with this client? "I know you have been abused. Please tell me about it." "Abuse is more prevalent than most people think." "What would you like me to know?" "What can I tell you about abuse?"

"What would you like me to know?"

Emergency medical services bring a client to the hospital after finding her unconscious in an alley. When the client regains consciousness, responses to assessment questions indicate to the nurse that the client may have been abused but that the client appears uncomfortable discussing the events. What open-ended question might be helpful when assessing abuse with this client? "What would you like me to know?" "Abuse is more prevalent than most people think." "What can I tell you about abuse?" "I know you have been abused. Please tell me about it."

"What would you like me to know?"

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? "He threw me against the wall and starting punching my face." "He yells at me for not having dinner waiting for him when he came home." "He calls me stupid and incompetent, asking himself why he ever married me." 'He tells me that he is sorry and that he will never hit me again."

'He tells me that he is sorry and that he will never hit me again."

The nurse plans to assess a 35-year-old female client for family violence. In which order should the nurse complete the HITS assessment tool? Rank the statements into the proper order. 1 How often does your partner physically hurt you? 2 How often does your partner scream or curse at you? 3 How often does your partner threaten you with physical harm? 4 How often does your partner insult or talk down to you?

1 4 3 2

A nurse assesses a client who was physically assaulted by his brother. The nurse learns that the client has been punched and kicked. After marking the area of injury on the body map, what score should the nurse document for this abuse? 4 5 3 1

3 (1 = Threats of abuse including use of a weapon 2 = Slapping, pushing: no injuries and/or lasting pain 3 = Punching, kicking, bruises, cuts and/or continuing pain 4 = Beating up, severe contusions, burns, broken bones 5 = Head injury, internal injury, permanent injury 6 = Use of weapon; wound from weapon)

A nurse is counseling a woman who has been abused by her husband and who is at risk for serious injury and even death. The woman has two school-aged children at home. Which of the following should the nurse tell the woman to make sure her children know? Select all that apply. A safe place to go when abuse of the client occurs That it is their job to keep their mother safe Who is safe to tell when they are unsafe How they should intervene during abuse to make it stop How and when to call 911

A safe place to go when abuse of the client occurs Who is safe to tell when they are unsafe How and when to call 911

When working with victims of abuse, there are many ways the nurse plays the part of a client advocate. What can the nurse do to be a client advocate? Select all that apply. Acknowledge injustice Help the client plan for future safety Respect client confidentiality Show sympathy to the client Respect the client's autonomy

Acknowledge injustice Help the client plan for future safety Respect client confidentiality Respect the client's autonomy

A toddler has been admitted to the pediatric intensive care unit (PICU) with scald wounds from a pan of hot water. The mother has been charged with child neglect, and the father is in denial of the cause of the injury to his son. A nursing diagnosis of dysfunctional family processes related to child neglect has been identified. The nurse caring for this client would use what appropriate nursing intervention in the client's care plan? Acknowledge the emotions experienced during stressful times Encourage the mother to hire an attorney for her defense Encourage verbalization of anger against the mother by the father Deny the father admission to the patient's hospital room

Acknowledge the emotions experienced during stressful times

When a nurse suspects that a client may have been abused, the first action should be to: Ask the client about the injuries and if they are related to abuse. Encourage the client to leave the batterer immediately. Set up an appointment with a domestic violence counselor. Ask the suspected abuser about the victim's injuries.

Ask the client about the injuries and if they are related to abuse.

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence? Ask, "Have you ever been physically hurt by your partner?" Call her home to ask her some questions about her marriage. Offer her a pamphlet about the local battered women's shelter. Wait until she comes in a few more times to make a better assessment.

Ask, "Have you ever been physically hurt by your partner?"

A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score? Beating up and severe contusions Head injury and internal injury Threat of abuse by weapons Punching and kicking

Beating up and severe contusions

When describing the cycle of violence to a community group, the nurse explains that the first phase usually is: Like a honeymoon that lulls the victim Associated with loss of physical and emotional control Somehow triggered by the victim's behavior Characterized by tension-building and minor battery

Characterized by tension-building and minor battery

A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? Assess the client for signs of psychological abuse Conduct a forensic interview Apply ice to the bruise on the client's face to reduce swelling Determine whether the boyfriend was abused as a child

Conduct a forensic interview

During a group session a victim of intimate partner violence describes the events that led up to the most recent episode of abuse. If using the Tension Building/Explosion Model, what should the nurse expect the victim to describe? Select all that apply. Honeymoon Guilt Set-up Criticism Battering

Criticism Battering Honeymoon (In the Tension Building/Explosion Model, there are three phases in the cycle of violence. The first phase is criticism, followed by battering, and ending with the honeymoon phase. Guilt and set-up are phases within the Cycle of Domestic Violence model.)

Many factors put older adults at risk for abuse. Which of the following are possible factors? Select all that apply. Decline in physical health of caregivers Strained mental health of caregivers Geographical location Cognitive decline Dependency

Decline in physical health of caregivers Strained mental health of caregivers Cognitive decline Dependency

What are some basic rules for nurses to follow when assessing for violence? Select all that apply. Demonstrate compassion, not judgment Be very patient when the client talks Ask only specific questions Perform assessment and screening only when the client is alone in a safe, private environment Make sure a family member is present

Demonstrate compassion, not judgment Be very patient when the client talks Perform assessment and screening only when the client is alone in a safe, private environment

The nurse is counseling a female victim of intimate partner violence. What should the nurse encourage the client to have prepared as part of a safety plan? Select all that apply. Credit cards Driver's license Marriage license Cash Bank account numbers

Driver's license Marriage license Cash Bank account numbers

A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse? Economic abuse Elder abuse Psychological abuse Child abuse

Economic abuse

The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing? Minimizing Intimidation Blaming Emotional abuse

Emotional abuse

Which technique should a nurse implement when interviewing with a child who has suffered physical abuse by the father? Ask questions that can be answered as "yes" or "no" Establish a reassuring environment Ask detailed questions with a lot of information Offer rewards to the child for answering

Establish a reassuring environment

What should a nurse be aware of before effectively assessing for the presence of family violence? Discuss any legal, mandatory reporting requirements Demonstrate a concerned and nonjudgmental attitude Need to create a safe and confidential environment Examine feelings, beliefs, and biases about violence

Examine feelings, beliefs, and biases about violence (Before starting an assessment of family violence, the nurse must examine his or her own feelings, beliefs, and biases about violence. Creating a safe and confidential environment, discussing any legal, mandatory reporting requirements, and demonstrating a concerned and nonjudgmental attitude are interview techniques the nurse should implement.)

A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply. Forcing an elder to perform a sexual act Having an elder sign financial documents without an understanding of what is being signed Failure to provide adequate nutrition to an elder Administering the wrong medication to an elder inadvertently Shoving an elder into a wheelchair

Forcing an elder to perform a sexual act Having an elder sign financial documents without an understanding of what is being signed Failure to provide adequate nutrition to an elder Shoving an elder into a wheelchair

A Hispanic mother brings her 2-year-old child to the clinic for a well-child checkup and age-appropriate vaccinations. Which of the following observations indicate potential abuse at home? Hand or finger-patterned bruising around upper arm and leg. Bruising across the lower back and upper buttocks bilaterally. Scraped and bruised knee. Symmetrical nickel-sized circular bruising across upper back.

Hand or finger-patterned bruising around upper arm and leg.

After reviewing a client's completed danger assessment questionnaire, the nurse determines that the client is in significant danger of intimate partner violence (IPV) leading to homicide. The client says that she would prefer to return home and that she does not have a safety plan. Which of the following nursing interventions should the nurse implement at this point? Select all that apply. Call the police and ask them to pick up the abuser. Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. Encourage the client to call with any concerns. Provide the client with contact information for shelters and groups. Schedule a follow-up appointment. Encourage the client to return home to avoid raising suspicion in the abuser.

Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. Encourage the client to call with any concerns. Provide the client with contact information for shelters and groups. Schedule a follow-up appointment.

After assessing a client and finding her positive for intimate partner violence (IPV), which of the following should the nurse do next? Interview the client and record subjective and objective findings Schedule a follow-up appointment with the client Ask the client whether she has a safety plan in place Have the client fill out a danger assessment questionnaire

Have the client fill out a danger assessment questionnaire

A nurse is working with a client who confides in the nurse that her boyfriend will not let her get a job and insists on controlling all of their money. He gives her only a small allowance each month to buy food and a few necessities. When the nurse offers information on how to seek help for economic abuse, the client just shakes her head and says, "It's no use. Nothing can be done." Which of the following nursing diagnoses would be most appropriate in this situation? Dysfunctional family processes related to family violence Anxiety related to not having enough money to purchase necessities due to significant other Risk for violence (other directed) related to taking out frustrations with an abusive partner on their children Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships

Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships

Which of the following are forms of psychological (emotional) abuse? Select all that apply. Humiliating Insulting Incest Threatening to destroy property Rape

Humiliating Insulting Threatening to destroy property

Which of the following is not a true statement about intimate partner violence? Intimate partner violence is caused by the "victim" refusing her husband's desire for sex. The annual cost in the United States for intimate partner violence exceeds $4 billion for medical and health services, and over $1 billion for lost productivity. One in every three women worldwide is a victim of intimate partner violence at some point in her life. Intimate partner violence is based on the abuser's need to maintain power and control over the victim.

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.

The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. While observing the interaction between the husband and wife, the nurse observes the husband shaking his fist at the wife. Which type of abusive or controlling behavior did the nurse observe? Coercion Intimidation Isolation Emotional abuse

Intimidation

A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting? Privilege Intimidation Isolation Coercion

Isolation

The community health nurse is reviewing recommendations from the US Preventive Services Task Force (USPSTF) to help identify risk factors for intimate partner violence. On which community factors should the nurse focus? Select all that apply. Lack of institutions Overcrowding Strict gender norms Neighbor unwillingness to intervene Marital instability

Lack of institutions Overcrowding Neighbor unwillingness to intervene

The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client? Readiness for enhanced family relationship Readiness for enhanced family health management Low self-esteem Risk for infection

Low self-esteem

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? Need for corrective lenses Undiagnosed neurologic disease Undiagnosed eye disease Nerve damage caused by repeated eye injuries

Nerve damage caused by repeated eye injuries

Which of the following is a stage in Walker's cycle of violence? Period of reconciliation. Reporting the problem. Ending the relationship. Hiding the abuse.

Period of reconciliation.

The nurse prepares an educational program on bullying for the students who attend middle- and high-school. What types of bullying should the nurse include in this presentation? Select all that apply. Financial Physical Relational Damage to property Verbal

Physical Relational Damage to property Verbal

A woman and her boyfriend bring the woman's 8-year-old daughter to the ED. The child has a fractured forearm and multiple bruises on her torso in various stages of healing. The fracture has already begun to heal. With what are these assessment findings consistent? Emotional abuse Physical abuse Emotional neglect Malnutrition

Physical abuse

A nurse is assessing a boy who appears to be undernourished. She can find no signs of physical abuse. She considers whether this may be a case of child abuse. Which of the following are included in the definition of child abuse? Select all that apply. Elder abuse Physical abuse Sexual abuse Emotional abuse Intimate partner violence Neglect

Physical abuse Sexual abuse Emotional abuse Neglect

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse? Economic Sexual Physical Psychological

Psychological

A client who is a victim of intimate partner violence (IVP), after undergoing a physical assessment of injuries she recently received from her husband, tells the nurse that she has had enough and is ready leave him, taking the children with her. She asks the nurse if the nurse knows of any safe places for her to go. Which of the following nursing diagnoses would be most appropriate for this client? Risk for powerlessness related to physical abuse by husband Low self-esteem related to lack of confidence related to presence of prolonged physical abuse Risk for violence (self-directed) related to ongoing history of being a victim of IVP Readiness for enhanced self-health management related to request for information on safe locations to go after leaving her home

Readiness for enhanced self-health management related to request for information on safe locations to go after leaving her home

A nurse is making rounds and checking on clients in an inpatient mental-health facility. As she walks into a client's room, she finda another nurse engaged in sexual relations with the client. What type of violence has this nurse observed? Hate crime Sexual violence Intimate partner violence Human trafficking

Sexual violence

An adult female client is being assessed for intimate partner violence (IPV). She acts as if the abuse she has suffered is normal. What could be a reason for her actions? She has a history of violence in her family She does not want to get into trouble She knows if she says anything she will be abused again She does not understand what constitutes violence

She has a history of violence in her family

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal? Teaching children about healthy touch Teaching women about the danger of men Increased electronic surveillance Reducing wage gaps between men and women

Teaching children about healthy touch

Why is it important for the nurse to wait until the end of the assessment interview to ask questions about violence in the client's life? This allows time to build rapport and to ask less sensitive questions first This allows time for the social worker to arrive, assess the situation, and decide on a course of action This allows time for the nurse to gain knowledge about the client and form judgments This time frame enables the physician to order specific tests to confirm violence

This allows time to build rapport and to ask less sensitive questions first

Which of the following are forms of psychological (emotional) abuse? Select all that apply. Incest Rape Threatening to destroy property Insulting Humiliating

Threatening to destroy property Insulting Humiliating

Nursing students are learning about human violence. The instructor is explaining key differences among various forms and how the differences affect assessment and intervention. What would the instructor explain is a key difference between violence against older adults and intimate partner violence? Family involvement Perpetrator Age Support people

perpetrator (Violence against older adults is intentional or unintentional acts such as physical, sexual, psychological, and financial abuse and neglect. Intimate partner violence is between spouses or nonmarital partners, threatened or actual physical or sexual violence or psychological/emotional abuse, coercive tactics, or both when there has been prior physical and/or sexual violence. Violence against an older adult can be perpetrated by someone other than the intimate partner. The other options are distractors for the question.)

When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should remain calm and accepting in response to any information the client discloses. offer a reward to the child for answering difficult questions. confine the interview to yes/no questions to keep the interview simple. ask leading questions to convince the child to offer information.

remain calm and accepting in response to any information the client discloses.