Chapter 10 - Assessing for Violence

A nurse is caring for a client who is a victim of intimate partner violence. The nurse determines further education is required regarding a safety plan when the client makes which of the following statements?

"I feel uncomfortable asking the neighbors to call the police when they hear a disturbance at my house."

The nurse is caring for a client who is a victim of intimate partner violence. The nurse determines the client has successfully developed a safety plan when the client makes which of the following statements?

"I have a packed bag ready, just in case."

The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation?

"I have not seen my parents in 6 months; they live only 30 minutes away."

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 a client for abuse and violence with every client encounter."

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?

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

What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

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

A nurse is explaining normal cultural considerations of children to a nursing student. The nurse determines understanding when the nursing student makes which of the following statements? Select all that apply.

- "Mongolian spots on the buttocks and backs of children may be normal in some populations." - "Raised red areas from coining or cupping may be seen in some ethnic groups."

While performing an initial assessment on a new 24-year-old female client, the nurse determines the client may be at risk for intimate partner violence when which of the following information is obtained? Select all that apply.

- client is currently unemployed - client describes self as a loner - client reports an unplanned pregnancy

A home health nurse visits an 80-year-old client with mild Alzheimer disease who recently moved in with a caregiver. Which observation(s) would cause the nurse to suspect neglect? Select all that apply.

- client's clothes are soiled - client's prescriptions have expired - client has lost 10 pounds in the past 2 months - client is hesitant to speak when the caregiver is present

What are some basic rules for nurses to follow when assessing for violence? Select all that apply.

- perform assessment and screening only when the client is alone in a safe, private environment - be very patient when the client talks - demonstrate compassion, not judgment

An emergency department nurse suspects a young client may be a victim of human trafficking when the nurse observes which of the following? Select all that apply.

- unable to state month or day - not allowed to speak for themselves - seems fearful and anxious - appears malnourished

A nurse suspects that a 9-year-old girl who is in the office today regarding a sprained wrist has been physically abused. The nurse would like to screen the girl for signs of abuse. The girl's father is in the examination room. What should the nurse do in this situation?

Ask the father to leave the room so that the nurse can talk with the child in private

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?"

During a general routine screening, a nurse identifies sexual assault. What is a priority nursing action?

Consult a sexual assault nurse examiner (SANE).

Which technique should a nurse implement when interviewing with a child who has suffered physical abuse by the father?

Establish a reassuring environment

A nurse administers the Elder Abuse Suspicion Index (EASI) on a 73-year-old client suspected of neglect. The client responds "yes" to three of the items. Which action should the nurse take next?

Further investigate suspicions of abuse or neglect.

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?

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

A female client and her partner come to the emergency department. The client has bruising on both upper extremities and a fracture of the left arm. The client states that she fell down the stairs. What finding would lead the nurse to suspect that the client is a victim of violence?

Partner states that client is very clumsy and accident prone

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?

Psychological

Police bring a client with substance abuse to the ED after being arrested for a domestic dispute in which he gave his wife a black eye. The client is out of control and verbally abusive; aggression against the staff is noted. When a nursing care plan is developed, what would be an appropriate nursing diagnosis for this client?

Risk for violence directed at others

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?

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

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

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

Which of the following are forms of psychological (emotional) abuse? Select all that apply.

- insulting - humiliating - threatening to destroy property

A nurse assesses a client who was physically assaulted by her boyfriend. The nurse learns that the client was stabbed in the thigh with a knife. After marking the area of injury on the body map, what score should the nurse document for this abuse?

6

Which of the following is true about violence against women?

Some experts purport that cultural attitudes influence violence.

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

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.

- neglect - physical abuse - sexual abuse - emotional abuse