Module 3.3 Abuse, Aggression, and Violence

A nurse manager is discussing sexual assault nurse examiners (SANEs) and the interventions they use when caring for clients have been sexually assaulted. Which of the following interventions should the nurse include?

A SANE offers client some options about their care.

A nurse is reviewing manifestations of nonsuicidal self harm (NSSH). Which of the following findings should the nurse identify as a warning sign that a client might be engaging in self-harm behavior?

A client is wearing long-sleeve shirts in hot weather

A nurse working at a community outreach center is speaking with a resident who reports, "I'm not sure where my child has gone they come by daily to bring me meals and help me with my medications. It's been over two weeks and I can't reach them." The nurse should identify that the client is experiencing which of the following types of abuse?

Abandonment

A nurse on an inpatient mental health unit is caring for a client. Select the three findings that require immediate intervention.

Aggressive behavior. Heart rate. Blood pressure.

A nurse is caring for a client who is becoming aggressive. Which of the following de-escalation techniques should the nurse use? (Select all that apply.)

Approach the client with respect. Respond to the client's concerns. Addressed the client in a soft voice.

A nurse on a mental health unit is caring for a client. The nurse should first address the client's _______________ followed by the client's ______________.

Auditory hallucinations. Restlessness and pacing.

A nurse is caring for a client who is speaking loudly and threatening to harm stuff and other clients. Which of the following medication should the nurse anticipate the provider prescribing for this client?

Chlorpromazine

A nurse is discussing nonsuicidal self harm (NSSH) with a newly licensed nurse. Which of the following statements should the nurse make?

Clients who engage in NSSH rarely seek medical attention.

A nurse on a mental health unit is reviewing a client's medical record. Click to identify if each action is performed during the assessment or intervention phase of the nursing process.

Determine if the client has a history of violence - Assessment Communicate with the client using simple terms - Intervention Administer an anxiolytic medication - Intervention Place the client in a low stimulation environment - Intervention Check the client for delusional thoughts - Assessment

A nurse is caring for a client who reports that their partner threatens them when they disagree about finances. The nurse should identify that the client is experiencing which of the following types of abuse?

Emotional

A nurse is caring for a client who was recently placed in seclusion due to their aggressive behavior. Which of the following statements made by the nurse indicates an understanding of the role the neurological system plays in relation to aggression?

Excessive amygdala reaction and inadequate regulation of the prefrontal area will increase the likelihood on aggression in the client.

A nurse is assessing a client who experienced abuse. Which of the following findings should the nurse expect?

Fear

A nurse is providing care to a client who has a history of violent behavior. The nurse should identify which of the following client statements as a risk factor for potential (future) violent behavior? (Select all that apply.)

I don't really have a lot to be proud of. I drink a half gallon of vodka every day. I occasionally use cocaine. I have been arrested two times for a domestic disturbance. Sometimes I yell at people who cut me off when I'm driving.

A nurse is caring for a client who is experiencing extreme anger. Which of the following client statements should the nurse identify as being consistent with adverse childhood experiences (ACEs)? (Select all that apply.)

My parents separated when I was nine years old. My siblings, and I would stay alone for days at a time while my parent was gone. My older sibling died of a heroin toxicity when I was 12 years old. My Parent used to hit my sibling and I with a belt when we were younger. When I was younger, I experienced drive-by shootings in my neighborhood.

A charge nurse is preparing an in-service for staff members about non-suicidal self harm (NSSH). Which of the following information should the nurse include?

NSSH is often used as a way to release painful emotions.

A nurse is providing care to a client who has a history of anger. The nurse should identify that comorbidities of anger include which of the following disorders? (Select all that apply.)

Posttraumatic stress disorder. Substance abuse disorder. Conduct disorder. Attention deficit disorder.

A charge nurse is providing an in-service to a group of staff nurses about the role of a forensic nurse. Which of the following information should the nurse include?

Provide legal testimony as requested by the client.

A nurse is caring for a client who has been physically abusive to others and was admitted to an inpatient mental health unit. Which of the following client behaviors should the nurse identify as early signs of potential aggression? (Select all that apply.)

Refusing to eat. Pacing the floor. Destroying items. Attempting to leave before discharge.

A nurse is presenting an in-service on the cycle of violence to nursing staff. The nurse should include that the perpetrator becomes affectionate at which of the following phases?

Respite

A nurse is evaluating a client whose partner is concerned about their episode of recurrent anger. Which of the following statements should the nurse make when explaining potential reasons for the client's anger? (Select all that apply.)

The client gets a rush of adrenaline when expressing anger. The client wants to harm someone they think harmed them. The client thinks their anger is justified. The client feels powerful when angry. When the client is angry, their self-esteem is boosted.

A nurse is providing teaching to a newly licensed nurse who is caring for a client experiencing aggression related to post traumatic stress disorder (PTSD). Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching?

The client has an excess of serotonin which results in aggressive behavior.

A nurse in the emergency department is caring for a client who states they fell down the stairs this morning. Which of the following assessment findings indicate the client might be experiencing physical abuse? (Select all that apply.)

The client has bruises in various stages of healing on their back. The client's eyeglasses are cracked. The client is visibly uneasy when their partner enters the area. The client has ligature marks around both wrists. The client has an open, discolored wound on their shoulder.

A home health nurse is conducting an initial assessment on a client. Which of the following findings should indicate to the nurse that the client is potentially experiencing neglect? (Select all that apply.)

The client indicates their toilet has been non-functional for the last few weeks. The client's bed linens, smell of urine. The client's home has stacked boxes and clutter blocking the walkways. The client's hair is dirty and tangled. The client has a stage one pressure ulcer on their coccyx.

A nurse is teaching a newly licensed nurse who is caring for a client who has previously demonstrated aggressive and violent behavior. Which of the following statements should the nurse make? (Select all that apply.)

The client's aggression might be linked to the history of schizophrenia. A client who has a traumatic brain injury may demonstrate violent behavior. A client who has bipolar I disorder, could be at higher risk for danger to others. A client who has been sexually abused might experience aggressive episodes. A client who has autism my experience episodes of aggression.

A nurse is caring for a client who experiences aggression. Which of the following statements made by the client indicates the client experiences hostile aggression?

They made me mad so I hit them.

A nurse is caring for a client who is demonstrating aggressive behavior towards others and is not responding to verbal interventions. Which of the following medication's to the nurse anticipate the provider prescribing?

Ziprasidone