Prep U chapter 9
A nurse is assessing a boy who appears to be undernourished. She can find no signs of physical abuse. She considers whether this may be a case of child abuse. Which of the following are included in the definition of child abuse? Select all that apply.
Neglect Emotional abuse Physical abuse Sexual abuse
A nurse reviews a client's past health history. Which information should cause the nurse to suspect that the possibility of abuse is present?
Repeated visits to the emergency room for injuries
The nurse is evaluating the risk for violence of a prenatal patient who has been accompanied by her partner. Which action by the nurse would be most appropriate? Select all that apply.
Perform a risk assessment for violence only when the patient is alone -Listen attentively and do not interrupt as the patient talks. -Do not judge the patient; be supportive during the interaction.
Which of the following is a stage in Walker's cycle of violence?
Period of reconciliation
Which of the following is a stage in Walker's cycle of violence?
Period of reconciliation.
The nurse is conducting the initial prenatal visit with a patient who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the patient describes isolation?
"I have not seen my parents in 6 months; they live only 30 minutes away."
The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?
"It looks like someone has hurt you. Tell me about it."
A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action?
"What are the dolls doing?"
Emergency medical services bring a client to the hospital after finding her unconscious in an alley. When the client regains consciousness, responses to assessment questions indicate to the nurse that the client may have been abused but that the client appears uncomfortable discussing the events. What open-ended question might be helpful when assessing abuse with this client?
"What would you like me to know?"
What are some basic rules for nurses to follow when assessing for violence? Select all that apply.
- Be very patient when the client talks -Demonstrate compassion, not judgment -Perform assessment and screening only when the client is alone in a safe, private environment
The nurse is helping a client who is a victim of intimate partner violence (IPV) develop a safety plan. Which of the following should be included in the safety plan? Select all that apply.
- Locations to go to if it becomes necessary to leave - What to pack and where to hide a bag or suitcase - A code word to use with kids, family, and friends that alerts them to danger
The nurse is evaluating the risk for violence of a prenatal patient who has been accompanied by her partner. Which action by the nurse would be most appropriate? Select all that apply.
- Perform a risk assessment for violence only when the patient is alone -Listen attentively and do not interrupt as the patient talks. -Do not judge the patient; be supportive during the interaction.
A nurse is screening an elderly woman for signs of elder mistreatment. Which of the following would be considered forms of elder mistreatment? Select all that apply.
- Refusing to assist the elder to the bathroom - Refusing to give the elder her medications - Having the elder sign papers she doesn't understand
Which of the following would the nurse identify as indicating psychological or emotional abuse? Select all that apply.
-Calling the victim names -Threatening to hit the victim -Forcing the victim to perform a degrading or humiliating act
After reviewing a client's completed danger assessment questionnaire, the nurse determines that the client is in significant danger of intimate partner violence (IPV) leading to homicide. The client says that she would prefer to return home and that she does not have a safety plan. Which of the following nursing interventions should the nurse implement at this point? Select all that apply.
-Schedule a follow-up appointment. -Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. -Provide the client with contact information for shelters and groups. -Encourage the client to call with any concerns.
A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply.
-Shoving an elder into a wheelchair -Having an elder sign financial documents without an understanding of what is being signed -Forcing an elder to perform a sexual act -Failure to provide adequate nutrition to an elder
Which of the following are forms of psychological (emotional) abuse? Select all that apply.
-Threatening to destroy property -Humiliating -Insulting -
A toddler has been admitted to the pediatric intensive care unit (PICU) with scald wounds from a pan of hot water. The mother has been charged with child neglect, and the father is in denial of the cause of the injury to his son. A nursing diagnosis of dysfunctional family processes related to child neglect has been identified. The nurse caring for this client would use what appropriate nursing intervention in the client's care plan?
Acknowledge the emotions experienced during stressful times
When a nurse suspects that a client may have been abused, the first action should be to:
Ask the client about the injuries and if they are related to abuse.
Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?
Ask, "Have you ever been physically hurt by your partner?"
A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score?
Beating up and severe contusions
A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point?
Conduct a forensic interview
When interviewing a client who is abused by the partner, the nurse should attempt to display which type of behavior towards the client?
Convey a concerned and nonjudgmental attitude
A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse?
Economic abuse
A Hispanic mother brings her 2-year-old child to the clinic for a well-child checkup and age-appropriate vaccinations. Which of the following observations indicate potential abuse at home?
Hand or finger-patterned bruising around upper arm and leg.
A nurse is assigned to care for a client who has been physically abused by her stepfather. The nurse finds that client has an abuse score of 5 in her documents. Which of the following descriptions corresponds to the abuse score?
Head injury and internal injury
A nurse is working with a client who confides in the nurse that her boyfriend will not let her get a job and insists on controlling all of their money. He gives her only a small allowance each month to buy food and a few necessities. When the nurse offers information on how to seek help for economic abuse, the client just shakes her head and says, "It's no use. Nothing can be done." Which of the following nursing diagnoses would be most appropriate in this situation?
Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships
Which of the following is not a true statement about intimate partner violence?
Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.
A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting?
Isolation
Police bring a client with substance abuse to the ED after being arrested for a domestic dispute in which he gave his wife a black eye. The client is out of control and verbally abusive; aggression against the staff is noted. When a nursing care plan is developed, what would be an appropriate nursing diagnosis for this client?
Risk for violence directed at others
Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal?
Teaching children about healthy touch
An important concept to teach preschoolers in an effort to prevent attacks of sexual abuse would be to first teach them
That their body belongs to them and they have the right to decide who can touch or look at it.
The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family?
The nurse must allow the elderly mother to decide if she wants to leave the situation or not.
Why is it important for the nurse to wait until the end of the assessment interview to ask questions about violence in the client's life?
This allows time to build rapport and to ask less sensitive questions first`
Which of the following is suggested for family abuse screening?
Universal screening for family and intimate partner violence is recommended.
The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should
make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication.
When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should
remain calm and accepting in response to any information the client discloses.
