Deck 32: Violence

Question 1

The nurse is providing care for a client who experienced several fractures as a result of spousal abuse.Which intervention is the most appropriate to include when planning care for the client?

A) Assist the client to devise a safety or escape plan.
B) Encourage the client to take charge of the situation.
C) Offer to contact outpatient services if the client promises not to return home after discharge.
D) Make it clear to the spouse that the couple needs to see a therapist.

Answer 1

Assist the client to devise a safety or escape plan.

Question 2

The nurse is providing care to a child who has suffered abuse.Which nursing actions are appropriate? Select all that apply.

A) Ask the child what he did to cause his parents to beat him so badly.
B) Tell the child that the individual who hurt them is a bad person.
C) Follow protocols for mandatory reporting.
D) Remind the child that he did nothing wrong.
E) Ask the child what really happened.

Answer 2

Follow protocols for mandatory reporting.
Remind the child that he did nothing wrong.

Question 3

The nurse is caring for a client that is the victim of domestic violence and is visited by the spouse in the hospital.Which action by the nurse supports the client?

A) Call the police to have the spouse arrested for assault.
B) Refuse to permit the spouse to visit with the client.
C) Call security to have the spouse removed.
D) Ask the client if there is anything that is needed at this time.

Answer 3

Ask the client if there is anything that is needed at this time.

Question 4

The nurse is providing care for a 2-year-old client.When assessing the client's risk for abuse,which increase this client's risk? Select all that apply.

A) The child has bruises on the knees and shins.
B) The child's parents are married.
C) The child is less than 3 years old.
D) The child is deaf.
E) The child's parents are unemployed and receive medical assistance.

Question 5

A client is brought into the emergency department after being in a motor vehicle accident.The client has suffered traumatic injury that may involve multiple body systems.Which is the priority nursing assessment for this client?

A) Breathing and ventilation
B) Circulation with hemorrhage control
C) Airway maintenance with cervical spine protection
D) Disability and neurological assessment

Question 6

An older adult client is brought into the emergency room after experiencing a fall.The nurse suspects elder abuse.Which assessment findings support the nurse's suspicions? Select all that apply.

A) Poor hygiene
B) Dehydration
C) Intracranial trauma
D) Fecal impaction
E) Dislocations

Question 7

The nurse is discharging a client,who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse.When the client states,"I hope this cast comes off before summer.Last night my husband promised me he is going to take me to Hawaii this summer.After he broke my jaw we went to Rome." Based on this data,which phase of violence is the client experiencing?

A) A tension phase
B) An abusive phase
C) A honeymoon phase
D) Reconciliation and healing

Question 8

A child is admitted to the hospital with physical injuries.Which assessment findings would indicate that the child is a victim of abuse? Select all that apply.

A) Confusion
B) Missing teeth
C) Inappropriate response to pain
D) Abrasions to the mouth, lips, and genitalia
E) Dehydration

Question 9

A young client is brought into the emergency department by a friend who says the client was "beat up" at school.The client is reluctant to provide the names of parents or a home address.Which should the nurse suspect has occurred with this client?

A) The client does not want the individual who did the beating to get in trouble.
B) The client does not know his parents.
C) The client does not want the school to get in trouble.
D) The client is a victim of interpersonal violence.

Question 10

A client who has experienced domestic violence in the past has decided to stop participating in counseling.Which client statement would indicate that therapy has been effective?

A) "Everyone knows what my problems are, and there is nothing I can do about it."
B) "I am functioning fine now but I know that when problems come up again, I will ask for help."
C) "My friends tell me that I have improved so this is a good time to stop."
D) "It is so draining to deal with the same painful issues all of the time."

Question 11

The emergency department nurse is caring for a client with multiple injuries.The client has had a diagnostic peritoneal lavage to determine the presence of blood in the peritoneal cavity.Which result would indicate to the nurse that the diagnostic test is considered positive?

A) The solution returns pale pink and is found to have a white blood cell count of < 500.
B) The solution returns pale pink and is found to have a red blood cell count of 50,000 mm³.
C) The solution returns pink and is found to have bile, food, or feces.
D) The solution returns clear and is found to have a red blood cell count of 90,000 mm³.

Question 12

The nurse is providing care to a client who is a victim of interpersonal violence.Which interventions are appropriate for this client? Select all that apply.

A) Educating the client on how to avoid future incidents of violence
B) Distracting the client to avoid overwhelming feelings about the situation
C) Using a supportive, nurturing approach
D) Helping the client identify intra- and interpersonal strengths
E) Maintaining objectivity and offering short, to-the-point responses

Question 13

A client with a long history of experiencing domestic violence tells the nurse,"There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate?

A) Powerlessness
B) Risk for Other-Directed Violence
C) Ineffective Health Maintenance
D) Chronic Low Self-Esteem

Question 14

A young adult female student is brought into the emergency department by her roommate.The roommate says,"She came home from a party at her boyfriend's house and said that he raped her." Which techniques are appropriate when assessing this client? Select all that apply.

A) Inquire how many sexual partners she has had.
B) Offer to use a rape evidence collection kit.
C) Ask her if she has ever had a sexually transmitted infection.
D) Assess for the presence of an intact hymen.
E) Ask her if she led her boyfriend on in any way.

Question 15

A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime.Which has the client identified based on this data?

A) A predisposing factor
B) A risk factor
C) A vulnerability factor
D) A precipitating factor

Question 16

A young female client presents to the emergency department with vague physical symptoms and does not make eye contact with the nurse during the interview.Which assessment question from the nurse is the most appropriate to gain understanding of the cause of the client's symptoms?

A) "What kind of problems are you having?"
B) "Can you tell me what's been going on in your life lately?"
C) "Is someone hurting you?"
D) "Can you explain what your family life is like?"

Question 17

The school nurse is leading a discussion on violence with a group of adolescents.Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply.

A) Involvement in the community
B) Participation in family activities
C) Residing in an impoverished community
D) Academic failures at a young age
E) Success in school

Question 18

A client is admitted with injuries sustained from a domestic dispute.When planning care,the nurse will include which short-term interventions? Select all that apply.

A) Explore options for self-development.
B) Improve quality of life by increasing self-esteem.
C) Explore options for help.
D) Convey safety.
E) Determine immediacy of danger.

Question 19

After an assessment,the nurse suspects a client with multiple injuries is a victim of domestic violence.Which action should occur next?

A) Conducting a team assessment
B) Medicating for anxiety as prescribed
C) Notifying the police
D) Treating the injuries

Question 20

A client recovering from injuries obtained from a domestic dispute asks to attend Mass at the hospital chapel.Which is the reason why this is important for the client?

A) Find a distraction from the injuries.
B) Attend to spiritual needs in order to deal with what has happened.
C) Show an interest in what is going on in the world.
D) Get back to a normal routine as soon as possible.

Question 21

The nurse is planning care for a client recovering from injuries sustained in a gang fight.Which interventions should the nurse include in the client's plan of care? Select all that apply.

A) Need for adequate rest and physical activity
B) Methods to reduce anger other than force or physical violence
C) Employment counseling
D) Monitor intake and output
E) Setting limits

Question 22

What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.

A) Airway maintenance
B) Obtaining medical history
C) Ventilation assistance
D) Hemorrhage control
E) Hypothermia prevention

Question 23

A client who was raped tells the nurse that she must not get pregnant.Which response by the nurse is appropriate?

A) "The baby could always be given up for adoption."
B) "You will not know for sure for at least a few more days."
C) "There is a medication called Plan B, which is emergency contraception."
D) "Are you sure the rapist did not use a condom?"

Question 24

A nursing instructor is educating a group of students on culture and diversity as it relates to homicide.Which statement made by a student nurse would indicate to the instructor that further education is needed?

A) "Caucasian individuals are more likely to use a gun as a means of homicide than any other weapon."
B) "Stranger homicides typically are not interracial."
C) "The homicide rate among African American individuals is considerably higher than that among individuals of other races."
D) "Caucasian individuals are significantly more likely to commit homicides involving multiple victims."

Question 25

A client,who was raped and refuses to see any male healthcare providers,tells the nurse that she had an "incident" that she does not want to talk about,and wants a bed by the door.Which nursing diagnosis is appropriate for the client?

A) Relocation Stress Syndrome
B) Readiness for Enhanced Power
C) Rape-Trauma Syndrome
D) Acute Confusion

Question 26

The nurse is providing care for a client who was the victim of sexual abuse 8 months ago.Which ongoing,long-term treatment goal is appropriate? Select all that apply.

A) Demonstrate effective coping strategies.
B) Involve significant others in the treatment plan.
C) Become aware of legal rights.
D) Establish rapport and build a trusting nurse-client relationship.
E) Move from victim to survivor status.

Question 27

The nurse is conducting a seminar regarding rape-trauma.Which does the nurse include as the underlying issue of most rapists? Select all that apply.

A) A desire to overpower and control
B) A desire to play out fantasies
C) An uncontrollably strong sex drive
D) The inability to control intense anxiety
E) Acting out aggression

Question 28

A client recovering from a rape tells the nurse that flashbacks do occur but can be managed.Which techniques should the nurse suggest to the client for managing flashbacks about the event? Select all that apply.

A) Restoring personal choice
B) Deep breathing
C) Muscle relaxation
D) Problem solving
E) Guided imagery

Question 29

The nurse is caring for a victim of rape.Which interventions should the nurse include in the client's plan of care? Select all that apply.

A) Notifying an attorney for the client
B) Supporting the victim during the examination
C) Identifying the individual who committed the rape
D) Treating acute injuries
E) Providing referrals for follow-up care

Question 30

A pediatric nurse is caring for an 18-month-old client.While making rounds the nurse enters the room and finds the infant's father violently shaking the infant.The father attempts to make it appear as though the infant was choking.Upon further assessment the nurse notes bruised areas on the infant's arms and legs.What is a priority action for the nurse to take?

A) Discuss what she witnessed with the infant's mother.
B) Discuss what she witnessed with the other nurses.
C) Report what she witnessed and assessed to child protective services.
D) Report what she witnessed and assessed to the local law enforcement agency.

Question 31

A client was admitted with a gunshot wound sustained during a robbery.What does the nurse suspect contributed to this client's injury?

A) The crime's suburban location
B) The gunman's unemployment
C) The gunman's age of 45
D) The gunman's college education

Question 32

A school-age client is admitted with dog bites and scratches obtained when throwing rocks at a neighbor's dog.Which action by the nurse is most appropriate?

A) Tell the client that he might go to jail for hurting the dog.
B) Ask the client where his parents were when he was hurting the dog.
C) Suggest to the client that it is not okay to harm animals.
D) Ask the client what he intended to accomplish by hurting the dog.

Question 33

A client is brought into the emergency department after being assaulted.It is suspected that the client has a spinal cord injury.Which diagnostic test does the nurse anticipate based on the data collected?

A) Computed tomography (CT) scan
B) X-ray
C) Ultrasound
D) Magnetic resonance imaging (MRI)

Question 34

The nurse is completing a morning assessment on an older adult Asian client.Assessment findings reveal circular red welts over the client's upper back with several bruised areas.Which nursing action is the most appropriate?

A) Contact adult protective services.
B) Call the healthcare provider immediately.
C) Assess the client's spiritual beliefs.
D) Contact the client's family.

Question 35

The nurse is conducting a community assessment regarding risk factors that increase an individual's risk of being raped.When educating the community about these risks,which will the nurse include? Select all that apply.

A) Previous history of being raped
B) Current substance abuse
C) Lives with parents
D) Attends community college
E) Unemployed

Question 36

What should the nurse do to assist a client brought to the emergency department as a victim of a gunshot wound?

A) Ask the client who shot him.
B) Bathe the client and provide a clean gown.
C) Ask the client where the weapon is.
D) Preserve the chain of evidence.

Question 37

A client with a history of frequent outbursts and fighting has been receiving treatment to help control emotions and anger.Which client statement shows that treatment has been effective?

A) "My brothers are the only ones I can fight with and not get in trouble."
B) "There are other ways to deal with anger, and I will use them instead of fighting."
C) "Hitting people is only justified sometimes."
D) "As long as my mother doesn't hit me first, I will not hit her."

Question 38

Security was contacted to remove a handgun from the pants pocket of a client who had been admitted with wounds sustained in a fight.Which nursing diagnosis should the nurse include in this client's care plan?

A) Risk for Violence to Others
B) Risk for Loneliness
C) Risk for Situational Low Self-Esteem
D) Fear

Question 39

The family of a victim of a gunshot wound is asking emergency department personnel if they could find out the status of their family member.Which action by the nurse is appropriate?

A) Suggest they go to the cafeteria to get something to eat or drink.
B) Suggest they return home, and the hospital will phone them with any information.
C) Contact social services or the hospital chaplain to provide support while they wait.
D) Escort the family to see the client.

Question 40

An adolescent client with fetal alcohol syndrome was arrested for assaulting another teenager after being distracted and missing the school bus.Which is the most likely reason for the adolescent's behavior?

A) Dislike of the other teenager.
B) Fetal alcohol syndrome.
C) Fetal alcohol syndrome and an environmental stressor.
D) Anger over being distracted.

Question 41

A client admitted with injuries after being involved in a motor vehicle crash states to the nurse,"every time I close my eyes I see the truck coming." Which is the priority nursing diagnosis for this client?

A) Post-Trauma Syndrome
B) Risk for Infection
C) Ineffective Coping
D) Anxiety

Question 42

An older adult male is transported to the emergency department after a motor vehicle crash.Which risk factors are most common for this age group? Select all that apply.

A) Unsafe driving practices
B) Preexisting health condition
C) Speeding
D) Texting
E) Reduced sensory perception

Question 43

A client often asks what life would be like if he had never been born or if he were to die.Which is the client at risk for based on this data?

A) A suicide attempt
B) Suicide planning
C) A suicide threat
D) Suicidal ideation

Question 44

The parents of a client who committed suicide are observed arguing in the emergency department waiting area.When planning care,which nursing diagnosis is most appropriate?

A) Risk for violence
B) Ineffective family coping
C) Anxiety
D) Situational low self-esteem

Question 45

The nurse is planning care for a client to prevent future suicidal behavior.Which interactions would be appropriate for this client? Select all that apply.

A) Add the names of community resources to a crisis card.
B) Assist in creating a crisis card listing family members.
C) Focus on reasons for living.
D) Limit exposure to friends.
E) Identify self-directed harmful behaviors.

Question 46

A nursing instructor is evaluating a nursing student's knowledge regarding a client with suicidal thoughts.Which statement made by the student demonstrates an understanding regarding assessing a client with suicidal thoughts?

A) "I should attempt to make light of the circumstances."
B) "I should be indirect and respectful."
C) "I should not talk about suicide directly."
D) "I should directly acknowledge the situation."

Question 47

An older adult client is admitted with fractured femurs sustained in a motor vehicle crash.Once the client is stabilized,what should the nurse assess in this client?

A) Blood pressure
B) Need for assistance once discharged to home
C) Car insurance carrier
D) The client's accident history

Question 48

A nurse is conducting an admission assessment on a client admitted for thoughts of suicide..Which assessment findings would indicate that the client is at a low level risk of suicide? Select all that apply.

A) Displays mild depression.
B) Shows curiosity about death.
C) Discusses taking his or her life.
D) Admits planning to end his or her life.
E) Discusses a plan to end his or her life in detail.

Question 49

The nurse working in the emergency department is aware that rape victims initially exhibit which emotions? Select all that apply.

A) Shock
B) Disbelief
C) Anger
D) Self-blame
E) Denial

Question 50

A rape victim is being seen in the clinic.Upon assessment it is discovered the client has contracted trichomoniasis.Which prescription does the nurse anticipate for this client?

A) Penicillin
B) Ceftriaxone and azithromycin
C) Metronidazole
D) Doxycycline

Question 51

An adolescent client hospitalized with asphyxiation from a failed suicide attempt tells the nurse,"I know other kids have the same problems I do,but I just wanted to make it stop." Which action by the nurse is the most appropriate?

A) Discuss the client's attendance at school and what activities are enjoyed.
B) Suggest the client listen to music and read a light novel to reduce stress.
C) Ask if the client would like to talk about stressors and problems.
D) Ask what is so devastating that the client needed to commit suicide.

Question 52

A client who has attempted to commit suicide in the past tells the nurse about feeling better since being prescribed an antidepressant medication.Which conclusion by the nurse is appropriate based on the assessment data?

A) Improved mood
B) Improved sleep
C) Improved feelings of guilt
D) Improved appetite

Question 53

A rape victim is being seen in the clinic.Upon assessment it is discovered the client has contracted syphilis.Which prescription does the nurse anticipate for this client?

A) Penicillin
B) Ceftriaxone and azithromycin
C) Tinidazole
D) Doxycycline

Question 54

The nurse is working with a client to create a crisis care card in the event the client wants to attempt suicide in the future.Which should the nurse include on this card?

A) Name of client's healthcare provider
B) Name of client
C) Address of client
D) Name and address of friends to call in case of a crisis

Question 55

A client recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation.Based on this data,which should the nurse suspect occurred?

A) Hemorrhage
B) Compensatory shock
C) Hypovolemic shock
D) Tension pneumothorax

Question 56

The nurse is providing care for a client who was raped.Which action by the nurse will help the client identify and prioritize concerns?

A) Help the client use problem-solving skills.
B) Provide anti-anxiety medication.
C) Tell the client that the event is over and it is now time to move on.
D) Instruct in guided imagery.

Question 57

The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash.Which is an appropriate client goal for the nurse to include in the plan of care?

A) Have an adequate urine output.
B) Regain mobility.
C) Participate in self-care activities.
D) Discharge to home.

Question 58

The nurse caring for a client recovering from a suicide attempt.Which client statement indicates that the plan of care was effective to eliminate the risk of future suicide attempts?

A) "I am not looking forward to going home with my parents."
B) "I now know that threatening suicide will help me get what I want from my parents."
C) "Even though I failed this time, I lived to think about it again."
D) "I am looking forward to going to school and seeing my friends."

Question 59

A nurse is interviewing a client who recently attempted suicide.Which question is appropriate for the nurse to ask the client?

A) "Do you currently have a plan for killing yourself?"
B) "Why would you think about hurting yourself?"
C) "Have you thought about hurting yourself?"
D) "Do you ever think about hurting yourself?"

Question 60

Which assessment findings increase a client's risk for suicidal ideation or behavior? Select all that apply.

A) Substance abuse
B) Age 59
C) Plays golf twice a week
D) Widowed for 6 months
E) Recently started a new job

Question 61

A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle crash.Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?

A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.

Question 62

A client is admitted to the emergency depeartment with an incomplete spinal cord injury.Which prescription does the nurse anticipate to decrease inflammation and nerve damage?

A) Hydrocodone (Vicodin)
B) Ibuprofen (Motrin)
C) Methylprednisolone (Medrol)
D) Xylocaine (Lidocaine)

Question 63

Which observation indicates that interventions provided to a client with neck injuries from a motor vehicle crash have been successful?

A) Urine is clear and odorless from indwelling catheter.
B) Moves all four extremities independently, feeds self, and participates in partial bath
C) Unable to move independently in bed
D) Rests in bed with lights and television turned off

Question 64

The nurse at a local hospital is conducting a safety workshop for expectant parents addressing newborn injury prevention and car seat safety.Which statement made by a parent indicates a need for further teaching?

A) "My newborn should be in a car safety seat every time he is in the car."
B) "It is good if I place a blanket over the baby and then buckle the baby onto the seat."
C) "My newborn should ride rear-facing until at least 1 year of age and more than 20 pounds."
D) "Never place a rear-facing car safety seat in the front seat with an active passenger air bag."

Question 65

Which intervention would be a priority when providing care to a client recovering from thoracic injuries sustained from a motor vehicle crash?

A) Monitor urine output.
B) Assess vital signs.
C) Perform passive range of motion to all extremities.
D) Assist to deep breath and cough every 2 hours.

Question 66

A client admitted for injuries sustained in a motor vehicle crash states to the nurse,"I was hurt much worse the last time I crashed the car." Which action by the nurse is appropriate to assist this client?

A) Report the client to the department of motor vehicles.
B) Find out what caused today's car accident.
C) Ask if he enjoys crashing his cars.
D) Suggest attending a driver's safety course to learn how to avoid crashes.