Violence
ANS: C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.
A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction
b. Jana is experiencing physical abuse and neglect.
Jana, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that Jana has numerous bruises on her arms and torso, in various stages of healing. She also notices some small scars. Jana's abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse suspects that: a. Jana is experiencing physical and sexual abuse. b. Jana is experiencing physical abuse and neglect. c. Jana is experiencing emotional neglect. d. Jana is experiencing sexual and emotional abuse.
d-Report suspicion of abuse to the proper authorities. The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse. The parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency. Although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate. Questioning the teacher may or may not provide validation of the nurse's suspicions; regardless, this intervention does not ensure the child's safety, which is the priority.
Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? a-Contact the child's parents and ask about the child's injury. b-Encourage the child to be truthful with her. c-Question the teacher about the parent's behavior. d-Report suspicion of abuse to the proper authorities.
d-The child has interest in things of a sexual nature. An 8-year-old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.
Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? a-The child is fearful of the caregiver and other adults. b-The child has a lack of peer relationships. c-The child has self-injurious behavior. d-The child has interest in things of a sexual nature.
When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? (Select all that apply.) A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by parental discord. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay in abusive relationships.
When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? (Select all that apply.) A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by parental discord. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay in abusive relationships.
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.
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
a. tending to the immediate care of her wounds.
A battered woman presents to the ED with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. The priority nursing intervention is: a. tending to the immediate care of her wounds. b. providing her with information about a safe place to stay. c. administering the prn tranquilizer ordered by the physician. d. explaining how she may go about bringing charges against her husband.
ANS: B The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.
A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the event as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the client's description of the event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.
ANS: A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.
A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. "I know that it was not my fault." B. "My boyfriend has trouble controlling his sexual urges." C. "If I don't put myself in a dating situation, I won't be at risk." D. "Next time I will think twice about wearing a sexy dress."
ANS: A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.
A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child might have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.
d. use a "family" of dolls to role-play the child's family with her.
A school nurse notices bruises and scars on a child's body, but the child refuses to say how she received them. Another way in which the nurse can get information from the child is to: a. have her evaluated by the school psychologist. b. tell her she may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse's questions. c. explain to her that if she answers the questions, she may stay in the nurse's office and not have to go back to class. d. use a "family" of dolls to role-play the child's family with her.
a. As a health-care worker, report the suspicion to the Department of Health and Human Services.
A school nurse notices bruises and scars on a child's body. The nurse suspects that the child is being physically abused. How should the nurse proceed with this information? a. As a health-care worker, report the suspicion to the Department of Health and Human Services. b. Check Jana again in a week and see if there are any new bruises. c. Meet with Jana's parents and ask them how Jana got the bruises. d. Initiate paperwork to have Jana placed in foster care.
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.
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?"
d. "I hope you have made the right decision. Call this number if you need help."
A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: a. "I just can't believe you have decided to go back to that horrible man." b. "I'm just afraid he will kill you or the children when you go back." c. "What makes you think things have changed with him?" d. "I hope you have made the right decision. Call this number if you need help."
b. provide physical and emotional support during evidence collection.
A young woman who has just undergone a sexual assault is brought into the ED by a friend. The priority nursing intervention would be to: a. help her to bathe and clean herself up. b. provide physical and emotional support during evidence collection. c. provide her with a written list of community resources for survivors of rape. d. discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.
b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."
Kate is an 18-year-old freshman at the state university. She was extremely flattered when Don, a senior star football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Kate to the emergency department. Kate says to the nurse, "It's all my fault. I shouldn't have allowed him to stop at the lake." The nurse's best response is: a. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to stop at the lake." b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d. "You'll just have to see that he is arrested so he won't do this to anyone else."
b-History of the parent having been abused as a child One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy functioning, not abuse. Single-parent households and a history of mental illness are not established risk factors for child abuse by a parent.
Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? a-Flexible role functioning between parents b-History of the parent having been abused as a child c-Single-parent home situation d-Presence of parental mental illness
c. Phase II. The acute battering incident that Sharon provoked with her threat to leave.
Sharon, a woman with multiple cuts and abrasions, arrives at the ED with her three small children. She tells the nurse her husband inflicted these wounds on her. In the interview, Sharon tells the nurse, "He's been getting more and more violent lately. He's been under a lot of stress at work the last few weeks, so he drinks a lot when he gets home. He always gets mean when he drinks. I was getting scared. So I just finally told him I was going to take the kids and leave. He got furious when I said that and began beating me with his fists." With knowledge about the cycle of battering, what does this situation represent? a. Phase I. Sharon was desperately trying to stay out of his way and keep everything calm. b. Phase I. A minor battering incident for which Sharon assumes all the blame. c. Phase II. The acute battering incident that Sharon provoked with her threat to leave. d. Phase III. The honeymoon phase where the husband believes that he has "taught her a lesson and she won't act up again."
b. "It is not your fault. You did the right thing by coming here."
Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department (ED) with her three small children. She tells the nurse her husband inflicted these wounds on her. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: a. "How often does he drink too much?" b. "It is not your fault. You did the right thing by coming here." c. "How many times has he done this to you?" d. "He is not a good husband. You have to leave him before he kills you."
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.
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, B An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders. Disturbed personal identity refers to an inability to distinguish between self and nonself and is seen in disorders such as autistic disorders, borderline personality disorders, dissociative disorders, and gender identity disorders.
Which of the following nursing diagnoses could be appropriate for an adult survivor of incest? (Select all that apply.) A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Noncompliance
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.
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