MH( AAV, (C,IPV,E abuse),sexual Violence, suicide)

A client has made a successful suicide attempt while hospitalized on a unit that specializes on the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement? 1. Suicide precautions for a full 24 hours will be implemented for all clients 2. All group therapy sessions will be held on the unit for at least a 72-hour period 3. A client focused psychological postmortem assessment will be conducted immediately 4. Every client will be questioned concerning the impact the suicide had on him or her personally

ANS: 1 A successful suicide attempt is a crisis situation for the unit. The safety of the milieu and of the individual clients are of primary importance. Since the unit focuses on clients diagnosed with depression all the patients on the unit need to be closely monitored for suicidal ideations. The first 24 hours after inpatient suicide is crucial for both safety and crisis management reasons. A postmortem assessment is conducted by staff and administrators to review policies and procedures that would be relevant to preventing such an occurrence. The remaining options are not therapeutic in this situation.

A client is currently expressing suicidal ideations. Which statement made by the client demonstrates knowledge of appropriate crisis management techniques that are focused on safety? 1. "I trust the staff here to help." 2. "I need you to stay with me." 3. "I know the thoughts will likely go away." 4. "I have survived the urge to kill myself before."

ANS: 2 During a suicidal crisis, it is important that the client understand that the crisis is temporary; unbearable pain can be survived; that help is available; and he or she is not alone. The knowledge most relevant to the client's safety is that he or she is not alone. Being attended to by another demonstrates that he or she is important and cared about. These are the feelings necessary to resist following through on his or her suicidal ideations.

When considering the lethality of a client's suicide plan, what is the basic principle the nurse will consider? 1. A gun can easily deliver a fatal wound 2. Ingesting pills is a slow method of self-harm 3. If the action is reversible, the plan is less lethal 4. Any suicide plan has the potential to be lethal I

ANS: 3 A plan that doesn't allow for a last minute reversal of the action is consider more lethal. While all suicide plans should be taken seriously, not all plans are considered lethal. The remaining options are true statements but not the guiding principle concerning determining a plan's lethality.

How will the nurse best assess a client for the current presence of suicidal ideations? 1. Carefully observe the client's nonverbal behaviors 2. Place the client on one-on-one suicide observation 3. Ask the client directly, "Are you thinking of killing yourself?" 4. Determine whether the client has ever acknowledged suicidal ideations

ANS: 3 If suicidal ideations are suspected, always ask directly, "Are you thinking of killing yourself?" None of the other options effectively assess the client for currently suicidal thoughts/ideations.

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

he feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you began feeling depressed

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, I will never be the same again. I cant face my friends. There is no sense of trying to go on. Select the nurses most important response. a. Are you thinking of suicide? b. It will take time, but you will feel the same as before. c. Your friends will understand when you tell them. d. You will be able to find meaning in this experience as time goes on.

ANS: A The victims words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.

A new nurse says to a peer, My newest patient is diagnosed with schizophrenia. At least I wont have to worry about suicide risk. Which response by the peer would be most helpful? a. Lets reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia. b. Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs. c. Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide. d. Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia.

ANS: A Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients diagnosed with schizophrenia. Patients diagnosed with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victims needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patients plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patients possession. c. Maintain arms length, one-on-one nursing observation around the clock. d. Check the patients whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patients whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patients possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury

ANS: A, B, E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.

When an emergency department nurse teaches a victim of the rape about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, D These reactions are common to the long-term reorganization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

A staff nurse tells another nurse, I evaluated a new patient using the SAD PERSONS scale and got a score of 10. Im wondering if I should send the patient home. Select the best reply by the second nurse. a. That action would seem appropriate. b. A score over 8 requires immediate hospitalization. c. I think you should strongly consider hospitalization for this patient. d. Give the patient a follow-up appointment. Hospitalization may be needed soon.

ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization

A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.

Which statement by a patient during an assessment interview should alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I shot myself.

ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by a military attack team d. Completion of alcohol withdrawal and beginning a rehabilitation program

ANS: C illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability

When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support

ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix everything but does not say it outright.

A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

ANS: C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommates absence from the dormitory. Terminating access to ones social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness.

A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorder

ANS: C, E Traumatic brain injury and post-traumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.

Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland

ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are most important and which are less important.

ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

A nurse answers a suicide crisis line. A caller says, I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. Im going to shoot myself in the heart. How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

A nurse working a rape telephone hotline should focus communication with callers to: a. arrange long-term counseling. b. serve as a sympathetic listener. c. obtain information to relay to the local police. d. explain immediate steps that a victim of rape should take.

ANS: D The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

. A severely depressed patient who has been on suicide precautions tells the nurse, I am feeling a lot better, so you can stop watching me. I have taken too much of your time already. Which is the nurses best response? a. I wonder what this sudden change is all about. Please tell me more. b. I am glad you are feeling better. The team will consider your request. c. You should not try to direct your care. Leave that to the treatment team. d. Because we are concerned about your safety, we will continue with our plan.

ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.

When considering an individual's risk for suicide, which client will the nurse consider the priority? 1. The older transgender female who has been repeatedly assaulted 2. The resent Middle Eastern immigrant from a war torn country 3. The teenager recovering from a self-inflicted gunshot wound 4. The gay male who has been diagnosed with HIV

Ans: 3 By far the strongest risk factor for suicide is a previous suicide attempt but there is growing concern over the high suicide rates globally among vulnerable groups who experience discrimination, such as refugees and migrants; indigenous peoples; and lesbian, gay, bisexual, transgender, and intersex (LGBTI) persons. Higher suicide rates are also seen among those who are incarcerated and those who live through war.

A family arrives at the emergency room with their injured child. After discrepant stories are given by the parents about the cause of the child's injuries, child abuse is suspected. Which diagnosis would be most appropriate for this family? a. Altered Family Processes b. Altered Family Coping c. Opportunity to Enhance Family Processes d. Risk for Altered Family Processes

B The most appropriate diagnosis for this family would be Altered Family Coping. Family coping refers to the family's patterns of interactions that have to do with its ability to provide sufficient and effective support, encouragement, or assistance to its members. When children are abused, it is related to a parent's inability to cope with the stressors he or she faces and consequently lashes out at the child.

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? A) "He always tells me that the abuse never happened." B) "He tells me who I can and cannot see." C) "He tells me that he'll tell child services I'm a bad mother." D) "He acts like he's the master of his castle and I'm his servant."

C

Which nursing diagnosis is the child likely to experience if the child is not successfully treated for psychological problems after physical or sexual abuse or neglect? a. Agitation, related to anxiety b. Depression, related to fear c. Post-trauma Response d. Post-traumatic Stress Disorder

C A child who has not been successfully treated for psychological problems after physical or sexual abuse or neglect will most likely be given a diagnosis of post-trauma response.

While making a home visit, a community health nurse sees evidence that the child of a patient has been abused. What rationale should be the basis for the nurse's nursing action? a. Privileged patient communication prevents the nurse from reporting the abuse. b. Documenting the evidence in the medical record supports the observation. c. A federal ruling requires that the nurse report the suspected abuse. d. A signed patient release is needed before action can be taken.

C Nurses are mandated reporters of suspected child abuse. To report or not is not discretionary.

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

The nurse is providing care to a toddler-age child. Which assessment finding is indicative of abuse? 1. Parents indicating that they did not see the event occur 2. Inconsistency of stories between caregivers 3. Bruising noted on the knees and shins 4. Acting out behavior of the child

Correct Answer: 2 Inconsistency of stories is a red flag for abuse. All other answers are logical explanations for this age group.

The nurse is answering questions at the community center about childhood sexual abuse. When asked which child is at greater risk for violence, the nurse responds: A) The male child. B) The firstborn child. C) The child who has a stepfather. D) The child with a physical disability.

D

The individual who should be assessed as being at greatest risk for demonstrating violent behavior is a. A, who has a history of spousal abuse. b. B, who is severely agoraphobic. c. C, who verbalizes hopelessness and powerlessness. d. D, who demonstrates bizarre somatic delusions.

A A history of prior aggression or violence is the best predictor of who may become violent. Option B: Clients with anxiety disorders are not particularly prone to violence unless panic occurs. Option C: Clients experiencing hopelessness and powerlessness may have coexisting anger, but violence is not often demonstrated. Option D: Clients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

A nurse working in a shelter for abused women would recognize that which of the following is a significant risk factor for intimate partner violence (IPV)? a. pregnancy b. depression c. asthma d. schizophrenia

A Pregnancy poses a significant risk for physical abuse. A pregnant woman may not have the physical ability to protect herself from the physical trauma to herself or her unborn fetus. Abuse during pregnancy can produce adverse reproductive outcomes such as prematurity and pregnancy loss.

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, I am considering suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to get help. c. We need to talk about the good things you have to live for. d. Bringing this up is a very positive action on your part.

ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, You have a lot to live for. It uses the patients ambivalence and sets the stage for more realistic problem-solving strategies.

The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipate that a loss of control is possible and plan accordingly. B) Explain the consequences the client will face if control is lost. C) Interview the client with another staff member present. D) Respond to verbal threats by terminating the interview and obtaining assistance.

B Feedback: Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression.

Which of the following behaviors would first alert the school nurse or teacher to suspect sexual abuse in a 7-year-old child? A) Extreme friendliness to peers B) Learning problems and shyness C) Telling sexually explicit stories to peers D) Withdrawn behavior and enuresis

C Feedback: Children who have sexual knowledge not expected at their age have often been sexually abused.

A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? A. "Why don't you consider doing volunteer work in a homeless shelter?" B. "Let's discuss the negative aspects of your life." C. "Things will look better in the morning." D. "It sounds like you are feeling pretty hopeless."

D This statement verbalizes the client's implied feelings and allows him or her to validate and explore them.

A physically or mentally impaired older female who is living with a relative and has a history of unexplained bruises or injuries, burns in unusual places, or poor personal hygiene is likely a victim of 1. neglect. 2. child abuse. 3. elder abuse. 4. adolescent abuse.

3 Characteristics of elder abuse

Which action is an example of anger? 1. Proposes radical changes to the way police manage public protesters at a town meeting 2. Writes a scathing letter to the local newspaper regarding corrupt local politicians 3. Slaps a spouse in the face during an argument about the family budget 4. Sets fire to the business that hires illegal immigrants

3. Anger is an unplanned reaction to a stressor. Although we are all familiar with the feelings of anger, not everyone responds to anger with aggression or violence in the same way. Anger becomes unhealthy if it gets in the way of a person's functioning or relationships or puts others at risk. Slapping in the midst of an argument is usually unplanned and an example of anger. The remaining options include planned expressions of frustration and/or aggression.

An older adult has experienced both physical and emotional abuse while living with a family member. The family member has been adherent with required therapy and at the client's request the two will again be living together. Which intervention will best assure that both the client and the family member's needs are being met? 1. Initially, 7 days a week, 24-hour home aides are provided 2. The client agrees to report any incidences of abuse by the family member immediately 3. The family member is informed that criminal charges will be filed if any abuse occurs 4. The home will have regular but unscheduled visits by adult protective services agents

4. Follow-up is crucial in ensuring ongoing safety of the elderly patient and support of the caregiving system. None of the other options provide long-term support and supervision.

A client with a history of being bullied has been admitted to the hospital for treatment of anger issues. Which classic reaction will the nurse address in the client's plan of care? 1. Paranoia 2. Somatic pain 3. Hallucinations 4. Suicidal ideations

4. Those who are bullied are prone to negative feelings about self, humiliation, poor self-concept, and great emotional pain, and many can suffer severe reactions that may last a lifetime, such as depression, posttraumatic stress disorder (PTSD), anxiety disorders, and even attempted or completed suicide. The remaining options are not necessarily associated with the client's diagnosis.

A teenage boy has been periodically beaten by his father. The boy tells the nurse, "He'll pay for this one way or another." The nurse treating his contusions should assess for behaviors suggesting: a. Aggression b. Depression c. Regression d. Withdrawal

ANS: A Research suggests that children who are abused are at high risk for antisocial behavior and associated aggressive behaviors for a period of at least 2 years after the battering incident. The boy's remark is not consistent with any of the other options.

A child was abducted and raped. Which personal reaction by the nurse could interfere with the childs care? a. Anger b. Concern c. Empathy d. Compassion

ANS: A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, There must be a mistake. This could not have happened. Weve given our child everything. The parents reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

ANS: A The parents statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario.

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, You may not leave until you receive prophylactic treatment for sexually transmitted diseases. b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victims comments.

ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.

A 16-year-old adolescent who was sexually abused as a child tells the nurse in the clinic that she is having nightmares about the boys in her class. Which outcome is a realistic short-term goal for her diagnosis of Sleep Pattern Disturbance? The client will: a. verbalize her anxiety and fear about sexual abuse b. identify goals for relationships with boys c. identify two ways to discuss her feelings with her mother d. state that she enjoys school

A The most appropriate outcome for the 16-year-old adolescent who was sexually abused as a child and is now having nightmares about the boys in her class would be to have her verbalize her anxiety and fear about sexual abuse. Verbalizing and acknowledging her feelings would be the first step in addressing the issue that is influencing her nightmares.

Which of the following psychosocial nursing diagnoses are related to anger and aggression? (Select all that apply.) a. Anxiety b. Violence, risk for other-directed c. Hopelessness d. Violence, risk for self-directed e. Coping ineffective, individual f. Fear

A, C, E, F Anxiety, hopelessness, ineffective coping, and fear are all potential nursing diagnoses related to anger and aggression. Violence, risk for other-directed and violence, risk for self-directed are diagnoses in the physical realm.

After a series of admissions to the emergency department over the past several months, an 80-year-old woman's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which of the following aspects of the woman's situation may contribute to elder abuse? (Select all that apply.) A) The woman is physically dependent on her son since she lost her mobility. B) The woman has no income or savings of her own. C) The woman's son describes her as "needy, helpless, and pathetic." D) The woman and her son are recent immigrants to the United States. E) The woman describes herself and her son as "not well-off, but not terribly poor either."

Ans: A, B, C 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.

The nurse is caring for a group of older adults. Which patients would the nurse recognize as being at greater risk for elder abuse? Select all that apply. 1. The patient with dementia who is cared for by family members. 2. The patient with dementia who is cared for by a paid caregiver. 3. The patient with depression who is cared for by family members. 4. The patient who is experiencing chronic anxiety and is cared for family members. 5. The patient who is grieving the loss of a spouse and is cared for by a paid caregiver.

Answer: 1, 2, 3, 4 Explanation: Older adults most at risk for elder abuse are those individuals with dementia and mental illness, regardless of who is caring for them. The patient who is grieving the loss of a spouse is not described as having a mental illness and is not at greater risk for elder abuse.

The nurse is caring for a patient whom the nurse suspects is a victim of intimate partner violence (IPV). What screening question made by the nurse is most appropriate? 1. "Can you tell me how you got your injuries?" 2. "Can you tell me if it is safe for you to go home?" 3. "Can you tell me what you know about intimate partner violence?" 4. "Can you tell me what your spouse was doing when you sustained your injuries?"

Answer: 2 Explanation: Screening is one way that nurses can help to provide information and resources to a person who may be suffering IPV. The most appropriate way to screen for IPV is the use of direct questions about the violence. The most appropriate question is, "Is it safe for you to go home?" All the other questions are not as direct, and they do not get at the priority nursing action, which is to assess the safety of the patient.

A patient has sat in stony silence in the day room for 20 minutes after her appointment with her psychiatrist. She appears tense and vigilant. The nurse sees the patient abruptly stand up and pace back and forth across the day room, clenching and unclenching her fists. She then stops and stares intently into the face of the psychiatric technician seated at a table. The priority assessment that should be made is that the patient is: a. working off the energy of angry feelings. b. attempting to use relaxation strategies. c. exhibiting clues to potential aggression. d. trying to work through her anger.

C The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. The patient's pacing may reduce some of the urge to respond physically, but this would be a secondary assessment and not as important to safety as are the signs of impending aggression and violence. The patient's behavior and nonverbal indicators are inconsistent with relaxation. The data are inadequate to determine whether the patient is trying to work through her anger, but this too would be a secondary observation.

When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unity involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? a. Monitor closely for harm to self or others b. Assist in completing an applicaiont for admission c. Supply the patient with written information about their mental illness d. Provide an opprotunity fo the family to discuss why they felt the admission was needed

(A) Monitor closely for harm to self or others RATIONALE: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the patient's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the patients' admission.

11. The nurse calls security and has physical restraints applied when a cliet who was admitted voluntarily becomes both physically and verbally abusive while demading to be discharged from the hospital. Which represens the possile legal ramifications for the nurse associated with these interventions? SELECT ALL THAT APPLY a. Libel b. Battery c. Assault d. Slander e. False Imprisonment

(B, C, E) Battery, Assault, False Imprisonment RATIONALE: False imprisonment is an act with the intent to confine a person to a specific are. The nurse can be charged with false imprisonment if the nurse prohibits a patient from leaving the hospital if the patient has been admitted voluntarily and if no agency or legal policies exist for detaining the patient. Assault and battery are related to the act of restraining the patient in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the patient.

A patient with a diagnosis of major depression who has attenpted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? a. "You have everything to live for" b. "Why do you see yourself as a failiure?" c. "Feeling like this is all part of being depressed." d. "You've been feeling like a failure for a while?"

(D) "You've been feeling like a failure for a while?" RATIONALE: Responding to the feelings expressed by a patient is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the patient's experience and do not facilitate exploration of the patient's expressed feelings. In additions, use of the word "why" is nontherapeutic.

On review of the patients record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient behavior? a. Fearfulness regarding treatment measures. b. Anger and agressiveness directed toward others. c. An understanding of the pathology and syptoms of the diagnosis d. A willingness to participte in the planning of the care and treatment plan

(D) A willingness to participate in the planning of the care and treatment plan RATIONALE: In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectations is the patient will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patients understanding of their illness, only of their desire for help.

A psychiatric nurse is providing an educational session to the emergency room staff to raise awareness on the topic of elder abuse. Which client is most at risk for elder abuse? 1. An 82-year-old woman with middle-stage dementia 2. A 73-year-old woman living in a poor neighborhood 3. A 70-year-old man with the recent diagnosis of heart disease 4. An 89-year-old man living with a mentally ill family member

1 Rationale: The typical elder abuse victim is a woman of advanced age with physical and/or mental impairment who usually depends on the abuser for care. The client with dementia is the most defenseless as the result of the disease process and requires significant hands-on assistance and care. Socio-economic factors are not relevant. Elders with health-related problems are often still capable of independent living and of attending to their needs.

A nurse is discussing the possible existence of abuse related to a 4-year-old currently being treated in the emergency department. Which statement by the nurse requires immediate intervention? 1. "A 4-year-old can be an unreliable source since they have such wonderful imaginations." 2. "It's up to the state's child protection agency to determine if our fears are valid." 3. "I'm absolutely sure every state requires that we report our concerns." 4. "We don't need physical proof of injury to report this situation."

1. When child abuse is suspected persons in authority including nurses, teachers, spiritual leaders, coaches, counselors, and child care providers are legally responsible for reporting to the appropriate child protective agency. Each state mandates that a report must be filed when suspected abuse or neglect is encountered. It is not necessary to have proof of the abuse. If there is a suspicion or the child says something is happening, that is enough grounds to report. It is then up to the CPS agency to investigate and make a determination.

Which client-focused change will the nurse identify as a sign of possible escalation of anger? 1. An impulsive client demonstrates introspection 2. A quiet client becomes talkative and loud 3. A manic client becomes withdrawn 4. A depressed client begins to cry

2 Anger involves an increase in energy. Signs and symptoms of anger may involve changes in mood and behavior from quiet to talkative and loud, from talkative to silent and withdrawn, from calm to angry, or from depressed to elated. The remaining options lack the demonstration of increased energy.

After the admission interview and assessment the emergency department nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused? 1. Provide the child with suggestions of other possible examples of abuse 2. Insist that the child be further assessed without the parents being present 3. Allow the child to pick one parent to be present during the remaining examination 4. Delay the assessment until the appropriate child protection authorities are present

2. In the case of suspected child abuse, after the initial interview with the parents, the child should be seen alone giving him or her a chance to disclose mistreatment. The child should not be prompted about possible abuse nor should the examination be delayed since these actions can affect the outcome of the assessment.

A nurse is conducting a family assessment to identify possible triggers for abusive behaviors. Which family characteristic will the nurse identify as such a trigger? 1. The father is the "stay-at-home parent" 2. The parents were teenagers when the children were born 3. The family only socializes with other immigrant families 4. The parents are of different ethnic and religious backgrounds

2. The classic frustration-aggression hypothesis proposes that when frustration is high in response to negative societal situations, frustration may lead to aggression. Early parenthood is considered such a stressor. None of the other options are recognized as triggers for possible family-centered abuse.

A client became angry with a staff member and began throwing objects at others in the unit. Which question will the nurse manager ask the staff in order to address the goals of the debriefing of the incident that focuses on client care? 1. "When did the violence begin?" 2. "What injuries resulted from the violence?" 3. "Were the unit's policies on managing violence followed?" 4. "What was the client's reasoning for the violent behaviors?"

3. Staff analysis of an episode of violence, referred to as critical incident debriefing, is crucial for a number of reasons. First, a review is necessary to ensure that quality care was provided to the patient. Staff members need to critically examine their response to the patient and so identifying policy driven responses is a part of the process. While the remaining questions are appropriate, they are not associated with the debriefing process.

Which question demonstrates the nurse's understanding of the need to assess a client who has been physically abused for additional forms of trauma? 1. "What types of injuries have you received as a result of the physical abuse?" 2. "Did your abuser ever intimidate or threaten you with physical harm?" 3. "Can you tell me when the physical abuse began?" 4. "Do you know what triggers the physical abuse?"

3. The physical damage caused by physical abuse is usually accompanied by emotional abuse. Emotional abuse includes threats and intimidation. The remaining options focus on the physical abuse/trauma.

Which statement, by a client diagnosed with poor impulse control, indicates an improved prognosis? 1. "Being angry is ruining my life." 2. "I feel so badly when I act on my anger." 3. "I've learned to walk away when I start feeling angry." 4. "My children will stop loving me if I continue to act this way."

3. An improved prognosis requires proof the behaviors are being managed or eliminated. The patient will recognize when anger and aggressive tendencies begin to escalate and employ at least one new tension-reducing behavior at that time (time outs, deep breathing, talking to a previously designated person, employing an exercise such as jogging). While the remaining options demonstrate self-awareness, they lack a strategy to manage the behavior.

An adolescent claims to have been physically abused by a parent. The adolescent's other parent angrily tells the nurse, "It's ridiculous for our child to accuse my spouse, who is a prominent doctor respected by the community.". The nurse responds: a. "Do you believe that abuse does not exist in well-respected, professional families?" b. "I know that it is difficult to believe what your child is saying about your spouse, but abuse has occurred.". c. "I know your spouse and I have never seen him be unkind or abusive to patients, but that is no proof of innocence.". d. "Your spouse seems to have a very stressful, demanding practice. That can be a risk factor for losing one's temper when angry.".

A The correct option effectively uses the therapeutic nursing communication of reflection. By reflecting back to the patient what she has said, the nurse assists the patient to view the statement in perspective.

An elderly client who lives with her daughter and son-in-law and their three children reveals that her daughter sometimes slaps her when she does not move fast enough or spills things. The daughter is a midlevel business executive who is under considerable stress at work. The chil-dren have many school activities to which they must be transported. The husband is often out of town on business trips. The daughter states, "I have so much to do that I become frustrated when my mother can't move fast enough or causes me extra work." The nurse caring for the mother could appropriately suggest: 1. Moving the mother to an adult ambulatory care facility 2. Employing an aide to provide care and stimulation for the mother 3. Enrolling in a therapeutic group that addresses stress management 4. Reading the elder law of the state to learn the penalties for elder abuse

ANS: 3 The daughter has many stressors and has few external supports. Enrolling in a stress management group would provide support as well as teach more new adaptive coping strategies. Options 1 and 2 are probably not necessary. Option 4 is threatening.

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to another room, and grabbing a snack from another patient .b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the persons underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

ANS: A Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

Which assessment data should a school nurse recognize as signs of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

ANS: A The nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patients privacy may be compromised by the presence of family. The rape victims anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victims family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

ANS: B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patients right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

A rape victim tells the emergency department nurse, I feel so dirty. Please let me take a shower before the doctor examines me. The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. She was very beautiful. b. I gave her what she wanted. c. I have issues with my mother. d. Ive been depressed for a long time.

ANS: B Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment

ANS: B Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

An adolescent tells the school nurse, My friend threatened to take an overdose of pills. The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?

ANS: B The nurse must assess the patients access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, I cant believe Ive been raped. This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

ANS: B The victims response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

ANS: B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. Reported should be used instead of alleged. Penetration should be used instead of intercourse. Declined should be used instead of refused.

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

A rape victim tells the nurse, I should not have been out on the street alone. Which is the nurses most therapeutic response? a. Rape can happen anywhere. b. Blaming yourself only increases your anxiety and discomfort. c. You believe this would not have happened if you had not been alone? d. You are right. You should not have been alone on the street at night.

ANS: C A reflective communication technique is helpful. Looking at ones role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victims perceived role and interfere with further discussion.

A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

ANS: C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not kill or harm myself in any way. d. I will not kill myself until I call my primary nurse or a member of the staff.

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, I am not going to harm myself, I am going to kill myself, or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan.

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid that next time he might kill me." Which is the appropriate nursing reply? A. "Leopards don't change their spots, and neither will he." B. "There are things you can do to prevent him from losing control." C. "Let's talk about your options so that you don't have to go home." D. "Why don't we call the police so that they can confront your husband with his behavior?"

ANS: C The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the "rescuer." Imposing judgments and giving advice is nontherapeutic.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patients discharge? a. Patient states, I feel safe and entirely relaxed. b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

A rape victim asks an emergency department nurse, Maybe I did something to cause this attack. Was it my fault? Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the persons level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: D Anxiety is the result of a personal threat to the victims safety and security. In this case, the persons symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety allow the person to function at a higher level.

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, I cant talk about it. Nothing happened. I have to forget! What is the persons present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: D Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patients statements do not reflect somatic symptoms, repression, or projection.

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

A patient is hospitalized after an arrest for breaking windows in the home of a former domesticpartner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women

ANS: D The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman might be a victim of incest.

ANS: D The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate reply? A. "These clients don't know life any other way, and change is not an option until they have improved insight." B. "These clients have limited KEY: Cognitive skills and few vocational abilities to be able to make it on their own." C. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

ANS: D The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, for financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.

The nurse is caring for a patient who appears anxious and is pacing the room and clenching his fists. What action best demonstrates the core concept of effective intervention for this patient? 1. Administering a medication to the patient 2. Deciding to promptly isolate the patient from others 3. Assessing the patient's perception of his level of anxiety 4. Demonstrating therapeutic communication with the patient

Answer: 4 Explanation: The patient in the scenario is displaying escalating anxiety, which may lead to aggression and violence. Interventions for a patient who is displaying anxiety, frustration, anger, and aggression are based on the core principle of therapeutic communication. Pharmacological therapy may be used in the treatment of this patient; however, this is not the core concept of effective intervention for this patient. While prompt decision-making is appropriate for this patient, isolating the patient is not and does not represent the core concept of effective intervention for this patient. While it may be appropriate to assess the patient's perception of his level of anxiety, this does not represent the core concept of effective intervention for this patient.

Which statement about aggression would accurately serve as a basis for care planning? a. Brain injury or disorders are often blamed for, but rarely contribute to, violence. b. Some people are biologically predisposed to become irritated or angry more easily. c. Aggression is an innate behavior rather than a learned response to frustration. d. Mature persons with patterns of effective coping almost never behave violently.

B Research suggests that a number of abnormalities in brain and neurotransmitter function can contribute to increased likelihood of violent behavior; some persons do seem to be biologically predisposed to tolerate frustration less well and respond more readily with anger or rage responses. Brain injury or disorders such as cerebrovascular accidents, dementia, temporal lobe epilepsy, and tumors can lead to increased violent behavior as well. Research also supports a role for aggression as a learned response, whether from observing violent role models within one's family or community or through exposure to violence in the media. Persons who have otherwise not shown a pattern of violence can nonetheless behave violently when their normal coping abilities have been overwhelmed.

The nurse caring for a client who was the victim of Intimate Partner Abuse (IPV) has identified the nursing diagnosis of "Ineffective Coping, related to a situational crisis secondary to ongoing cycle of violence, as evidenced by inability to ask for help." A possible outcome objective for this diagnosis would be which of the following? a. The client will state reasons her husband needed to hurt her. b. The client will verbalize her feelings, strengths, and needs. c. The client will state that she deserved to be battered. d. The client will not press charges against her husband.

B The most appropriate outcome for a nursing diagnosis of "Ineffective Coping, related to a situational crisis secondary to ongoing cycle of violence, as evidenced by inability to ask for help," is for the client to verbalize her feelings, strengths, and needs. The other outcomes do not demonstrate improvement in the client's thinking.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.

B The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating. The nurse should conduct a thorough assessment of the client's past and current violent behaviors and develop interventions for de-escalation.

A nurse works with a person who was raped four years ago. This person says, It took a long time for me to recover from that horrible experience. Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

B. A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

A nurse is examining a 75-year-old woman and finds evidence of ongoing physical abuse. Upon asking, the woman reveals that her 75-year-old husband hits her on occasion. The woman asks the nurse not to disclose this information to the police. The nurse understands that: a. in any case of abuse, the nurse is required to disclose the information to the police, regardless of the client's wishes b. the nurse is free to use her own judgment as to whether or not she should inform the police c. because this is a case of elderly abuse, the nurse is required to disclose the information to the police regardless of the client's wishes d. because the abuser is the client's husband, it is not considered a case of elderly abuse; therefore the nurse cannot disclose the information to the police against the client's wishes

C The nurse is required by law to report all cases of suspected elder abuse to the proper authorities. The nurse is also obligated to report cases of child abuse.

A visiting nurse notices bruises on an elderly client's face and legs. When she questions the client about the bruises, the client is very evasive. The nurse suspects that the client has been a victim of elder abuse. What should the nurse do next? a. Call protective services to report the suspected elder abuse. b. Confront the client's caregiver and threaten to notify the police. c. Continue questioning the client to assess the degree of abuse. d. Return in 2 weeks to reassess the client's condition.

C The nurse should continue to question the client to further assess the situation. If elder abuse is confirmed, the nurse should then contact the protective services.

The school nurse is working in a culturally and ethnically diverse school in which there have been a large number of documented incidences of violence. Which of the following ideas would the nurse stress early in the health class before proceeding to training in such subjects as anger management? a. We are all unique in some way, and uniqueness is wonderful. b. You are going to end up hurt someday when you pick on the wrong person. c. Every child deserves courtesy and respect no matter what background the child has come from. d. Aggression is a bad way to interact with others and will be punished.

C. Correct. Developing a curriculum with culture and ethnic sensitivity is important but difficult to implement in schools with an interracial mix of students; it is better to stress that every child deserves courtesy and respect no matter their background.

A child is admitted to the hospital unit with physical injuries. The nurse is taking the child's history. Which statement by the parent would arouse suspicion of abuse? 1. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I was walking up the steps and slipped on the ice, falling while carrying my baby."

Correct Answer: 2 All of the statements made by the parent are plausible from a developmental perspective except the statement "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib.

An older adult patient exhibits bilateral bruising for the second time on both upper outer arms. When the nurse questions the patient about the bruising, the patient starts to cry and pleads, "Please don't say anything. It's not my daughter's fault. I just bruise easily.". Which intervention reflects the best management of this situation? a. Calling the daughter to discuss both the bruising and her parent's reaction b. Reporting the elder abuse and informing the patient and the daughter of the action c. Notifying the patient's social worker of the bruising after a complete assessment has been completed d. Informing the patient and the daughter of the nurse's obligation to document the bruising and report the findings to protective services

D Although it is often difficult to differentiate elder abuse, bilateral bruising on the upper outer arms is a definitive sign. The nurse is responsible for reporting such findings and continuing vigilant observation for further signs of elder abuse and neglect. It is usually best to inform the family of your intention to report elder abuse with the expressed purpose of obtaining help for both; this makes protective services less threatening and preserves the nurse's therapeutic alliance.

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

A nurse working in an home health agency, which provides services to elderly client, would understand that which client is MOST at risk for possible elder abuse? a. a 66-year-old woman who lives with her son and experiences poor mobility b. a 72-year-old woman who lives alone and has no income except for Social Security c. a 75-year-old man who lives alone and has a good income from investments in the stock market d. an 83-year-old woman who livers with her daughter and has no income except for Social Security

D Research has shown that individuals over 80 years old are at greatest risk for elder abuse. This situation compounded with the fact that her only income is Social Security places her in a dependent position.

A nurse performing an admission interview identifies a need for one-to-one supervision when the patient admits to having suicidal ideations with a plan. The best way to inform the patient of the planned intervention is to say: a. "We cannot trust you to remain safe, so someone will always be with you.". b. "It is our policy to have a staff member stay with all new admissions to the unit.". c. "The hospital can't let you hurt yourself. Someone will stay with you at all times to protect you from self-harm.". d. "I understand your impulse to harm yourself. A staff member will stay with you to help you control that impulse.".

D This explanation is honest and suggests caring as well as collaboration between the nurse and patient. The other choices are impersonal and do little to convey caring

A patient who was abused as a child tells a nurse of the abuse in a stilted, unemotional manner. Which intervention would encourage the patient to examine feelings associated with childhood abuse? a. "You poor thing! I feel deeply sorry for what you endured.". b. "When you described this relationship, you didn't tell me how you felt.". c. "You must be feeling so angry with your parents that you'd like to harm them.". d. "If I experienced that as a child, I would feel betrayed, confused, and frightened.".

D When patients have difficulty describing feelings, the nurse can use the technique of verbalizing how he or she might have felt in the same situation. This demonstrates the nurse's empathy for the patient.

A nursing instructor is teaching a class of nursing students about anger, aggression, and violence. Which statement by the instructor would be most appropriate to include? A) "Anger, aggression, and violence are points along a continuum." B) "The terms used to describe anger are very precise." C) "Anger is a knee-jerk reaction to external events." D) "Women experience anger as frequently as men do."

D Women experience anger as frequently as men do, but societal constraints may inhibit their expression of it. Anger, aggression, and violence should not be viewed as a continuum because one does not necessarily lead to another. Language related to anger is imprecise and confusing. People can choose to slow down their reactions and to think and behave differently in response to events; therefore, anger is not a knee-jerk reaction to external events

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents

D An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression.

The nurse is leading a community session on violence prevention. When teaching a group of parents how to deal with aggression in their children, it is important for the parents to learn to: A) Avoid talking about violence altogether; children's curiosity causes them to try out the new behaviors discussed. B) Talk to their children about violence. C) Offer to solve the problem for children who are faced with conflict to teach them that there are answers to their conflicts. D) Role-play anger and show the extreme side of the behavior so children realize that in a similar situation, there is a high chance they will get hurt.

b

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A persons lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.