Ch 12 - Abuse and Violence PrepU
Importance of measuring the clients' progress in small steps Nurses must become accustomed to measuring gains in small steps when working with survivors. Making any changes in significant relationships has serious consequences and can be done only when the adult survivor is ready. It is easy to become angry or discouraged with survivors, so it is important not to communicate such feelings. Discussing such feelings with other staff provides a way of dealing with them appropriately. In such discussions with supervisors or other staff, it is a must to protect the patient's confidentiality by discussing feelings around issues, not particular patients.
A nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff?
material abuse The older adult population is susceptible to abuse and/or neglect. Physical abuse indicators include frequent and unexplained injuries, reluctance to seek medical treatment, disorientation or drowsiness, and fear or edginess in the presence of family members or caregivers. Psychosocial abuse indicators include a change in the client's mood or usual behavior, isolated from previous friends or family, sudden lack of contact from other people, helplessness, hesitance to talk openly, anger or agitation, or withdrawal or depression. Material abuse indicators include unpaid bills, standard of living below the older adult's means, sudden sale or disposal of the older adult's property, unusual activity in bank accounts, signatures on checks that differ from the older adults, and recent change in advance directives when the older adult is not capable of making those decisions. Neglect indicators include poor personal hygiene, lack of needed medications or therapies, dirt or health hazards in the living environment, rashes or sores, malnourishment or dehydration not related to an illness, and inadequate material items. Therefore, the nurse suspects material abuse in the older adult
A nurse working in case management has noticed that a client who is not capable of making their own decisions has recently had a change in their advance directive documentation and has unpaid bills. Which type of older adult abuse does the nurse suspect the client may be experiencing?
The client is physically dependent on the client's son since losing mobility. The client has no income or savings of the client's own. The client's son describes the client as "needy, helpless, and pathetic." Physical and financial dependence and personality conflicts with caregivers and children are known to contribute to elder abuse. Low socioeconomic status and recent immigration are not identified as causative factors.
After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply.
delay in seeking treatment for a significant injury, inconsistencies or changes in the history of the child, evidence of old injuries no reported, high incidence of UTI's As with all types of family violence, detection and accurate identification are the first steps. Signs that may lead the nurse to suspect abuse or neglect include serious injuries such as fractures or lacerations with no reported history of trauma, delay in seeking treatment for a significant injury, child or parent giving an inconsistent history with the severity of the injury, inconsistencies or changes in the child's history, unusual injuries for the child's age or developmental level, high incidence of urinary tract infections or swollen genitalia, and evidence of old injuries not reported. The finding of the child or parent giving a history consistent with the severity of the injury would not be concerning for abuse or neglect at this time.
An emergency department (ED) nurse is conducting the initial assessment on an 8-year-old child. Which assessment finding(s) would be concerning for possible abuse or neglect? Select all that apply.
65% Approximately two-thirds of women are raped by people they know, including spouses, boyfriends, friends, or acquaintances. Among young women, about 50% of rapes are date rapes.
Approximately what percentage of women rape victims are raped by someone they know?
Several small, circular burns on the child's back Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries are not uncommon. A small area of ecchymosis is not suspicious in this age group.
In a toddler, which injury is most likely the result of child abuse?
Giving back the survivor as much control as possible is important. Knowing how to recognize when personal feelings are likely to interfere with optimal care is part of the nurse's professional responsibility. Giving back the survivor as much control possible is important by allowing the client to make decisions about who to call, what to do next, and what the client would like done in relation to the crime. The nurse's role in helping the survivor regain control is an essential part of recovery.
Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why?
educating about perpetrator behaviors indicative of losing control Safety planning includes providing education to the client regarding manifestations that are indicative that the perpetrator is losing control. Teaching about sleep hygiene is an intervention that promotes healthy daily activity. Guardianship paperwork may be necessary for older adult or children who are survivors of abuse; however, this is not appropriate based on the current client data. Providing the client with supplies needed to treat injuries addresses the client's physical health.
The nurse provides care for a client who reports intimate partner violence (IPV). Which intervention does the nurse include in the client's plan of care to address safety planning?
ecchymosis to the arms Assessment is essential to determine the cause for the infant's poor feeding because infants are at a high risk for dehydration. Infants do not begin to move or ambulate on their own prior to the age of 6 months, when they begin to crawl; therefore, any bruises on an infant before the age of 6 months is cause for suspicion. Based on this information, the finding that indicates a need to assess for child abuse is ecchymosis to the arms. Although a diaper rash could be indicative of neglect, this infant's rash is mild and is not a finding that supports the need to assess for child abuse. The sunken fontanelle and dry mucous membranes support a diagnosis of dehydration, which is why the pediatrician advised the parents to report to the ED.
The nurse provides care to a 4-month-old infant who presents to the emergency department (ED) with the parents at the advice of the pediatrician due to poor feeding and potential dehydration. Which finding noted by the nurse during the physical examination indicates the need to assess for child abuse?
The belief that his masculinity will be in question It is a common misconception that males cannot be sexually abused, that only "sissies and weaklings allow abuse," leading to the possibility that his masculinity is at stake if he is identified as a victim.
The psychiatric nurse recognizes that a male rape victim is less likely to report the crime due to which reason?
Bruises, burns, lacerations, missing teeth, and skeletal injuries The most common indicators of physical abuse of a child are as follows: (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.
When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present?
the client's father monitors contact with friends has a family history of alcohol abuse must go straight home after school each day Having contact with friends monitored by the father indicates there is an abuse of power and control in the home. Having to go straight home after school indicates the client is being forced into social isolation. In addition, there is a family history of alcohol abuse. These are all characteristics of violent families. Adolescents commonly report feelings of being left out and experiencing social pressures to experiment with drugs and alcohol. These are not characteristics of violent families.
When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.)
Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or in public. It can also involve actions such as destroying another's property, threatening or harming pets, controlling or monitoring spending and activities, or isolating a person from family and friends. Rape and incest are forms of sexual assault.
Which are forms of psychological abuse? Select all that apply.
Children at high risk for sexual abuse include those who • Are aged 3 years or younger • Suffer from a developmental delay • Live in a home where substance abuse occurs • Have adolescent parents or a single parent • Are in foster care • Have primary caretakers who were sexually abused themselves • Have primary caretakers who are mentally ill or have a developmental delay
risk factors for child sexual abuse?
Shaken baby syndrome Despite its name, shaken baby syndrome has been documented in children up to 5 years of age. The physical findings usually include bruising from being grabbed firmly along with major head injury, such as subdural hematoma or cerebral edema. Nonfatal consequences include blindness due to retinal hemorrhage.
A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition?
positive pregnancy test Violence sometimes begins or escalates when a pregnancy occurs. Abuse during pregnancy is a significant risk factor for several fetal and maternal complications, including miscarriages, low birth weight, low maternal weight gain, infections, and anemia. Pregnancy is a window of opportunity for health care providers to screen women for intimate partner violence and refer them to the appropriate services. A low calcium level is not an indicator for IPV. A low red blood cell is associated with anemia that can occur during pregnancy; however, it is not an indication of IPV. A normal blood glucose level is not associated with IPV.
A client arrives for a follow-up appointment to receive the results of laboratory tests. For which result would the nurse take the opportunity to assess the client for intimate partner violence (IPV)?
"Be careful because the time of leaving is the greatest risk." If victims attempt to leave or actually do leave the relationship, perpetrators often escalate their violence, stalk their partners, and may even kill them, which makes leaving the time of greatest risk in an abusive relationship. For this reason, the nurse should counsel the client to be careful. Leaving the relationship when the partner is at work might not be a good time to leave. Advising to have money and writing down the day and time of leaving is not essential. The client's safety is paramount and that should be the focus of the nurse's suggestion.
A client in an abusive relationship reports planning to leave the home the next time the partner is at work. Which suggestion would the nurse provide to the client?
"It is not your fault." "I am glad that you told me." "I am required to report this abuse." "I am really sorry this happened to you." When survivors are disclosing abuse, they need privacy and time to tell their story. The nurse should listen attentively without offering unsolicited advice or making judgmental remarks about the possible abuse or the perpetrator. Use validating messages to convey that the survivor is believed and that the nurse is concerned for their safety and well-being. Examples of such messages include "It is not your fault." and "I am glad you told me." and "I am really sorry this happened to you." Although the nurse may be required to report the incident, this response is not therapeutic. Additionally, adult clients must be allowed an appropriate degree of autonomy in deciding how to manage the problem, even if the choice is to remain in the abusive situation. Telling the client that they should leave their spouse is judgmental and will likely affect the therapeutic nurse-client relationship.
A client present to the emergency department (ED) with a rib fracture and states, "I am so clumsy! My spouse always tells me that I need to be more careful." The client's spouse is asked to leave the exam room for the assessment. When the spouse is gone the client states, "My spouse doesn't mean to hurt me. I usually push too hard, and they just loses control!" Which response by the nurse is appropriate? Select all that apply.
Ensure client confidentiality. Explain mandatory reporting requirements. Meet in a quiet private place for the interaction. Survivors of IPV are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality, disclosing any mandatory reporting responsibilities, and providing a quiet, private place in which to interact. Asking for reasons the client stays in the relationship will place the client on the defensive and harm the nurse-client relationship. The nurse needs to understand that not everyone is going to be willing to talk about the situation. Explaining that refusing to talk about the situation will make it worse is threatening to the client and may cause the nurse-client relationship harm.
A client seeks medical attention for injuries caused by intimate partner violence (IPV). Which information would the nurse provide to support open communication with the client? Select all that apply.
use "I feel" statements Anger and rage are part of the healing process for survivors and should be expected. Anger management techniques include appropriately recognizing and labeling anger and expressing it assertively. Assertive ways of expressing anger include owning the feeling by using "I feel" statements. Reenacting the abuse, relaxation techniques, and reading stories about survivors are appropriate techniques to help a child who is a victim of abuse.
A client who has been victimized repeatedly by a spouse is angry and verbally lashing out on the nurse. Based on the client's behavior, which technique would the nurse use with this client?
"Actually, fewer than 2% of all reported rapes are found to be false." Rape is an underreported crime due to feelings of guilt on the part of the victim. Only approximately 2% of all reported rape cases are false.
A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer?
A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic Women who are pregnant have frequent contact with the health care system, creating a useful opportunity for IPV screening. None of the other listed situations precludes screening, but none are as ideal as frequent appointments at a consistent setting.
A nurse is aware of the high incidence of intimate partner violence (IPV) and actively seeks opportunities to screen women for IPV. Which female client represents the best opportunity for assessing for IPV?
The nurse must allow the older adult client to decide whether to leave the situation. Removing children and older adults from their families or caregivers often is necessary to ensure immediate safety. If the home of an abused or neglected child or older adult cannot be made safe, the nurse must facilitate other professionals involved in placing the child or older adult in a foster home or nursing home. Still, intervening in cases of older adult abuse is not a clear-cut issue. When an older adult's decision making is not impaired (competence is the legal term), they must be allowed an appropriate degree of autonomy in deciding how to manage the problem, even if the choice is to remain in the abusive situation. Forcing someone to do something against their wishes is in itself a form of victimization and denies autonomous decision making.
A nurse is caring for a family in which the older adult parent has been a victim of abuse and neglect by a middle-aged adult child. Which element should the nurse to keep in mind before interviewing the family?
Unemployed young woman who dropped out of high school Perpetrators of fatal child abuse are most likely to be caregivers who are young, poorly educated, and living at or below poverty level.
A nurse is giving a talk about child abuse to a local community group. When discussing risk factors for child abusers, which would the nurse identify as the most likely profile of the perpetrator of fatal child abuse?
Victims in same-sex couples often receive less support. Nonheterosexual couples experience IPV at rates similar to heterosexual couples, but victims often receive less support as a result of social stigma associated with nontraditional relationships. Nearly one in four women and one in nine men are victims of IPV at some point in their lives. Women are much more likely than men to be seriously injured as a result of IPV and to require medical treatment. The reaction to IPV may differ by gender.
A nurse is reviewing information about intimate partner violence (IPV). The nurse demonstrates understanding of this topic when the nurse identifies which information?
Recognizing the signs of danger One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.
A nurse is working on developing a safety plan with a client who is a survivor of violence. Which aspect of the plan would the nurse address first?
Multiple intellectual, physical, behavioral, and emotional arenas Maltreated children tend to have difficulties in social, behavioral, emotional, and intellectual functioning, as well as physical growth and development.
A nurse is working with a child whose parents have subjected him to neglect and emotional maltreatment, which primarily took the form of unavailability and general disinterest in his welfare. The nurse should expect that a child subjected to this type of maltreatment would experience problems in which of the following?
"It can take at least a year or more to get back to where you were before." It often takes one or more year for survivors of rape to regain previous levels of functioning. It is important to remind clients that it is possible to return to previous levels of functioning. Clients have many strengths that they don't realize. It is important for the nurse to avoid using the word "victim" and help the client identify as a survivor. The nurse should help the client focus on the present rather than dwell on horrific things from the past.
A nurse is working with a client who is a survivor of rape. The client asks the nurse, "It's been 6 months since it happened. Why can't I get back into doing the things I did before?" What is the nurse's best response?
Access to community resources for referral Much of the support and treatment that will be needed for women in abusive relationships is needed in the community. Having access to these resources is the most critical aspect to ensuring effective and sustainable support for women in abusive situations. An IPV counselor in the emergency department will only be available for support when there is an acute situation for which the client has come to hospital. Such a component is effective but not a long-term option to support people in abusive relationships. A quality of life assessment tool is effective for assessment, but this is only the initial part of the plan. Written educational materials are important to enhance knowledge for women in abusive situations; however, community support services are needed to ensure follow through and sustainability.
Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which component is critical to the success of the plan?
child crying and appearing sad Children who witness intimate partner violence are often overlooked as abuse victims. Witnessing violence puts children at risk for developing depression which can be demonstrated by crying and appearing sad. Reluctance to play with other children could have many causes however does not indicate intimate partner violence in the home. Helping with household chores and limiting television time are not indications that the child is exposed to intimate partner violence in the home.
The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment?
"do you experience migraines?" "how often do you get bladder infections? In addition to injuries and death, survivors suffer multiple conditions directly caused by IPV or the chronic stress associated with it. Examples of health problems associated with IPV include asthma, gastrointestinal conditions, cardiovascular problems, bladder infections, migraines, joint pain, gynecological disorders, and sexually transmitted infections (STIs). Based on this information, the questions the nurse asks the client include, "Do you experience migraines?" and "How often do you get bladder infections?" Determining the date of the client's last menstrual period is an appropriate assessment question; however, it is not specific to comorbidities associated with IPV. Asking if the client's partner threatens to harm pets or forces sexual intercourse are appropriate to determine the type of violence the client experiences; however, these questions do not focus on determining comorbidities associated with IPV.
The nurse assesses a client who states, "My partner physically abuses me." Which question(s) does the nurse ask the client to determine comorbidities associated with intimate partner violence (IPV)? Select all that apply.
abandonment Although abandonment can cause neglect and lead to physical and emotional abuse, abandonment is the primary type of abuse that this person is experiencing. The older person is calling for help because the caregiver has not been present for days. Neglect is the failure to meet basic needs of shelter and food. Physical abuse is causing injury by hitting, kicking, or pushing. Emotional abuse is injuring the person's self-worth and emotional well-being.
The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement?
sexual assault nurse examiner Examination for sexual abuse may require referral to a trained registered nurse in sexual assault, known as a SANE (sexual assault nurse examiner). This person is specially trained in protecting evidence. The healthcare provider on call and the client's primary care provider are not the appropriate professionals to contact to collect evidence from a rape. The charge nurse would not be appropriate either.
The nurse is assessing a victim who is brought into the hospital after being found badly beaten and raped by an unknown person. Which healthcare professional should the nurse contact to collect evidence of the assault?
honeymoon period This period of contrition or remorseis sometimes called the honeymoon period. The client naturally wants to believe their spouse and hopes the violence was an isolated incident. After this honeymoon period, the tension-building phase begins; there may be arguments, stony silence, or complaints from the spouse. The tension ends in another violent episode, after which the abuser once again feels regret and remorse and prom- ises to change. This cycle continually repeats itself. Each time, the victim keeps hoping the violence will stop.
The nurse is caring for a client that comes to the clinic with a black eye and states it was done by the partner but that it won't happen again since they sent flowers and apologized. Which stage of abuse does the nurse educate the client regarding?
"I am so sorry that you have been hurt." The nurse should express empathy but not advise the client about what to do in the relationship, such as leave. This may endanger the client more than staying. The nurse should not infer that it is the client's fault for antagonizing the abuser. The nurse should not give advice to attend couples counseling since it may further endanger the client.
The nurse is talking with a client that says they have been in a physically abusive relationship for years and just cannot leave it. Which response by the nurse is most therapeutic?
"My husband monitors my cell phone calls every month when the bill arrives." There are three phases in the cycle of violence: phase 1 is tension building, phase 2 includes the eruption of violence, and phase 3 includes remorse from the abuser. During the tension building phase, it is not uncommon for the abuser to monitor the victim's activities, including phone calls; therefore, the statement "My husband monitors my cell phone calls every month when the bill arrives." exemplifies this stage. The statements indicating that the husband begged the client not to leave after the last abusive incident and a lack of physical violence since the previous incidence both indicate phase 3 of the cycle of violence. Flowers to celebrate a pregnancy could indicate phase 3; however, the nurse should explore this statement further before making this determination.
The nurse provides care to a client who presents for an initial prenatal appointment. When reviewing the client's medical record, intimate partner violence (IPV) is documented. Which client statement made during the health history interview indicates phase 1 of the cycle of violence?
The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection The nurse's suspicion that a child has been sexually abused is supported when the assessment data includes a bruised anal area, itching reported by the child, an edematous vulva, and a urinary infection. Ear infections are common among children.
The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply.
Neglect, in this case, is the malicious withholding of a physical necessity for this child's well-being. For this child, the neglect is intended to be punitive for bed wetting. The nurse would need to investigate further and take the necessary action in reporting this as abuse. Sexual abuse refers to sexual acts performed by an adult on a child under the age of 18. Physical abuse refers to a deliberate physical assault by an adult on the child such as burning, biting, poking, or twisting a limb. Psychological abuse refers to verbal assaults such as blaming, screaming, name-calling, and using sarcasm. Although any of these could be contributing factors to the bedwetting, there is at present no evidence that sexual, physical, or psychological abuse is occurring. Therefore, the nurse will identify that the child is being neglected.
The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse?
Criticizing, Ridiculing, Threatening a victim's dog Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or public. It can also involve actions such as destroying another's property, threatening or harming pets, controlling or monitoring spending and activities, or isolating a person from family and friends. Asking the client for time alone when frustrated or using assertive language reflect healthy, adaptive communications skills during conflict management. These are not examples of psychological abuse.
What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply.
the child who wears hearing aids Children with special physical health-care needs are bullied more often, and children with a chronic emotional, behavioral, or developmental problem are more likely to be a victim of bullying. While any child may be a target for bullying, none on the other children have the obvious risk factor that a special needs child brings about.
Which child has the greatest risk for being the target of bullying at school?
"I've been supported by health care professionals and now I want to support other survivors." Nurses with a personal history of abuse or trauma must seek professional assistance to deal with these issues before working with survivors of trauma or abuse. Such nurses can be very effective and supportive of other survivors but only after engaging in therapeutic work and accepting and understanding their own trauma. The nurse should not repress the memories of the trauma but rather engage in the work needed to accept the incident. The other options present true statements but none are associated with being prepared to provide the necessary care.
Which statement, made by a nurse who experienced sexual abuse as as a child, demonstrates being best prepared to work with sexual abuse and trauma survivors?
