Exam 5: Violence & Abuse
A client is receiving treatment for injuries sustained during a fight with a partner. The nurse observes the partner visit the client daily in the hospital and appears very solicitous and contrite. The client states, "My partner always apologizes and brings gifts after a fight." Which response by the nurse is appropriate?
"Although your partner seems sorry, often an abuser will continue to repeat the behavior in the future."
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?"
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 16-year-old pregnant client presents to the office for the third time this week. While completing the client's admission, the nurse screens for intimate partner violence. The client responds, "I have already told you twice this week I am not being abused. Why do you keep asking me these questions?" Which response by the nurse is best?
"It is protocol to screen all clients for intimate partner violence at every visit."
After teaching a class about intimate partner violence to a group of young adults, the nurse determines that additional teaching is needed based on which statement by the group?
"People who are battered typically come from lower socioeconomic groups.
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.
The nurse is assessing a client whose partner is present. The nurse notes the partner swears and yells, makes lavish promises, and threatens to hit the client. Which nursing intervention is a priority?
Ask the partner to leave the room
A pregnant client with multiple bruises in various stages of healing comes to the clinic for treatment. She appears withdrawn and quiet when the nurse approaches her. Her partner accompanies her to the exam room and begins to answer for the client. There is minimal eye contact from the client to the nurse. Which action will the nurse complete next?
Have the client's partner leave the room.
A 19-year-old male client is brought to the emergency department after being raped. Which nursing action is most appropriate at this time?
Listen to the client's description of what happened.
The nurse is caring for a client who was raped approximately 10 hours ago. The client states, "I do not want to have a baby by whoever did this to me." Which action will the nurse do next?
Notify the health care provider.
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
A client has recently been treated in the emergency department for trauma to the head as a result of intimate partner violence (IPV). The client states to the nurse the desire to go back home to the partner upon discharge. Which action will the nurse take first?
Provide the client with components of an IPV safety plan.
A client at 25 weeks' gestation and her partner are at their first prenatal visit. While performing the admission history, the nurse notes several contusions in multiple stages of healing on the client's body. The client's partner answers all of the nurse's questions. Based on these observations, which is the most appropriate nursing intervention at this time?
Take the client to an isolated room to continue the assessment.
The nurse is assessing a client who is a victim of intimate partner violence and recognizes a belief that is common among victims of abuse. Which belief would the nurse most likely identify?
The client is inadequate in some way.
When teaching a group of young adults about the cycle of violence, the nurse would describe which behavior as eventually disappearing as the violence becomes accelerated over time?
apologies for the pain and abuse
Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)?
flashbacks
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
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.
sexual abuse physical abuse emotional abuse financial abuse
A nurse is working in a local community health care facility where many clients are victims of intimate partner violence. For which sign(s) will the nurse assess to determine if a client is a victim? Select all that apply.
-mental health disorders such as depression, anxiety, or substance use disorder -injuries on the face, head, and neck -reported history of the injury inconsistent with the presenting problem
A nurse is preparing a presentation for a local community group about intimate partner violence. Which statement would be most appropriate for the nurse to include in the presentation?
Intimate partner violence in lesbian, gay, bisexual, transgender, queer (LGBTQ) relationships may go unreported for fear of harassment.
When implementing an intervention for a client experiencing intimate partner violence, what is the primary goal?
The client will regain a sense of control in life.
A 13-year-old adolescent is admitted to the health care facility with vaginal bleeding. A genital examination reveals unhealed wounds likely resulting from female genital cutting. The client has limited proficiency in the dominant language. The service of an interpreter is employed. What should the nurse keep in mind when interacting with this client?
Use pictures and diagrams to supplement the questions and answers of the client's understanding
The nurse educator is preparing to teach a group of nurses about intimate partner violence (IPV). Which statement will the nurse include in the teaching session?
"IPV is a common form of violence among people in relationships."
Which statement made by a male client who has a history of perpetrating intimate partner violence reflects a known factor that is characteristic of this behavior?
"My classmates always called me a bully."
A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?
"My partner tells me that I will be turned into child services for being a bad mother."
A new nurse in the emergency department is caring for a pregnant woman who was beaten by her partner. Which statement by the new nurse would require intervention from the supervising nurse?
"That woman must be doing something to get beaten like that."
A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client?
Being nonjudgmental
A nurse is conducting an awareness session on sexual abuse, and she is explaining the psychological profile of an average abuser. Which trait is often displayed by abusers?
They exhibit antisocial behaviors.
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. -Poor weight gain during the pregnancy and low-birth-weight infant -The partner is overly protective of the pregnant client.
