Chapter 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 nurse is performing a physical examination of a pregnant woman. During examination, the nurse notices a bruise on the client's abdomen. Which action should the nurse take?

Ask the client to account for the bruise.

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

Promotes the client's sense of safety

The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases?

hopeless stage

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

A client at 34 weeks' gestation comes to the clinic with her partner and reports neck and back pain. During the assessment, the nurse notes multiple contusions in various stages of healing on the client's torso and weight gain of 3 lb (1.36 kg) during the course of the pregnancy. Which action will the nurse take next?

Have the client's partner leave the room during the examination.

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

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

The nurse suspects a client is a victim of intimate partner violence (IPV). Which statement by the client supports the nurse's suspicion?

"My spouse refuses to let me go out to find a job."

The nurse suspects a pregnant client is a victim of intimate partner violence (IPV). When the nurse asks the client if her partner abuses her, the client responds, "Oh no, my partner does not hit me." Which response by the nurse is most appropriate?

"There are many types of intimate partner violence beyond physical abuse."

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

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?"

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

A nurse is screening a client for intimate partner violence using indirect questions. Which question would the nurse most likely ask?

"Clients with your injuries are often abused. Is anything like this happening now?"

The nurse presents information on intimate partner violence (IPV) to a group of community members. The nurse will provide additional teaching when a community member makes which statement?

"I am lucky my spouse loves me. Genuine love will prevent me from being a victim."

While performing an assessment on a female client, the nurse notes signs of sexual assault. When questioned, the client states, "I am married, so I have not been raped or abused." What statement by the nurse is most appropriate?

"If you do not consent, it is still assault when you are married."

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 triage nurse receives a phone call from a client stating, "I was just raped and I need help. What should I do?" Which response by the nurse is a priority?

"Tell me if you are in a safe location away from the assailant now."

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

Building trust

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant

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