Community - Violence Elsevier missed questions

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time?

*Degree of control over the behavior* - Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.

A nurse has learned that infants born to very young mothers are at risk for neglect or abuse primarily because an adolescent characteristically:

*Is involved in seeking her own identity* - Adolescent parents are still involved in the developmental stage of resolving their own self-identity; they have not sequentially matured to intimacy and generativity, making nurturing of another difficult. Although adolescents usually do not plan for their pregnancies, it is not the primary reason that their infants are at risk for neglect or abuse. Although adolescents may have difficulty anticipating their infants' needs, it is not the primary reason that their infants are at risk for neglect or abuse. Although adolescents may resent the responsibilities involved in childrearing, it is not the primary reason that their infants are at risk for neglect or abuse.

Child maltreatment is suspected in a 3-year-old girl admitted to the hospital with many poorly explained injuries. Which statement by the mother further supports this suspicion?

*"I have no problems with any of my other children."* - Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt suspicions of physical abuse and warrants further investigation. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to his or her room alone is an acceptable punishment for misbehavior. Although making a child stand in the corner is demeaning, it is not physical abuse.

A nurse in the emergency department notes large welts and scars on the back of a toddler who has been admitted for an asthma attack. What additional information must be included in the nurse's assessment?

*Signs of child abuse* - When unexplained injuries are found, further assessment is required because it is the nurse's legal responsibility to report suspected child abuse. History of an injury is just one aspect of the assessment for child abuse. The presence of food allergies is not related to scars on the child's back. Although chickenpox may leave scars, it does not cause welts.