Chapter 10: Assessing for Violence

A nurse is educating a victim of intimate partner violence about a safety plan. The nurse should include which of the following?

Have a code word to use with your children, family, and friends that indicates you need help.

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.

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

Locations to go to if it becomes necessary to leave

A list of signs that indicate risk for IPV

A process for having weapons removed from the house

During the assessment of an adult client at the clinic, the nurse finds indications that the client is a victim of abuse. When documenting findings, the nurse knows that it is important to be what?

Descriptive

Non-biased

Detailed

A home health nurse visits an 85-year-old client who is being cared for by their adult child. Which findings require follow-up?

Client does not make eye contact

Client allows their child to answer questions

Client refuses to allow the nurse to perform a head-to-toe assessment

Blood pressure of 90/56 mm Hg

Client is unkempt, with wrinkled and stained clothing that appears too large

Mucous membranes look dry and lips are chapped

Which of the following is not a true statement about intimate partner violence?

Intimate partner violence is caused by the "victim" refusing their spouse's desire for sex.

The nurse is caring for a family in which the older adult parent has been a victim of abuse and neglect by their 48-year-old adult child. Which of the following would be most important for the nurse to keep in mind before interviewing the family?

The nurse must allow the older adult client to decide if they want to leave the situation or not.

The emergency department nurse is assessing a client with traumatic injuries. To assess whether or not the client's injuries have resulted from intimate partner violence, which question would be most appropriate for the nurse to ask the client?

It looks like someone has hurt you. Tell me about it.

While performing an initial assessment on a new 24-year-old female client, the nurse determines the client may be at risk for intimate partner violence when which of the following information is obtained?

Client is currently unemployed.

Client describes self as a loner.

Client reports an unplanned pregnancy.

The nurse is presenting an education program for a local community group about intimate partner violence. Which statement made by a member of the group indicates that the education is effective?

Men who experience intimate partner violence report fear and concern for their safety."

A nurse reviews a client's past health history. Which information should cause the nurse to suspect abuse?

Repeated visits to the emergency department for injuries.

What are the recognized types of family violence?

Child maltreatment

Elder abuse

Intimate partner violence

Bullying

A home health nurse visits an 80-year-old client with mild Alzheimer disease who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect?

Client's clothes are soiled.

Client's prescriptions have expired.

Client has lost 10 pounds in the past 2 months.

Client is hesitant to speak when the caregiver is present

Which of the following is true about violence against females?

Some experts purport that cultural attitudes influence violence.

The nursing instructor is educating students on the importance of assessing for victims of abuse and violence. What statement by the students indicates an understanding of when to assess for abuse and violence?

I will assess a client for abuse and violence with every client encounter.

Based on the nursing assessment, the nurse has formulated a nursing diagnosis of risk for post-trauma syndrome for an older adult. Which assessment data supports this nursing diagnosis? Select all that apply.

The older adult rarely makes eye contact when interacting with the nurse.

The older adult provides vague answers to questions without elaboration.

The caregiver of a cognitively intact older adult answers the nurse's questions.

Which observation of a client should cause the nurse to investigate further for intimate partner violence?

Wears long sleeves in warm weather.

During a general routine screening, a nurse identifies sexual assault. What is a priority nursing action?

Consult a sexual assault nurse examiner (SANE).

Which of the following would the nurse describe as a characteristic of the second phase of the cycle of violence?

The physical battery is abrupt and unpredictable.

the nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?

Nerve damage caused by repeated eye injuries.

An emergency room nurse receives a report on a sexually abused child. The nurse expects which of the following to be present? Select all that apply.

Irritation and swelling of genitalia

Appears older than stated age

Rarely makes eye contact and mumbles

A teenage client is in the emergency department. The client has a long medical history of injuries, including burns, bruises, and broken bones. The nurse suspects child abuse and asks the client's parent to wait outside. The parent hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. Which question is least appropriate for the nurse to ask the client?

Do you want me to report this?"

Many factors put older adults at risk for abuse. Which of the following are possible factors? Select all that apply.

Dependency

Cognitive decline

Strained mental health of caregivers

Decline in physical health of caregivers

Geographical location

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.

The nurse suspects intimate partner violence in a client they are assessing. When interviewing the client, which statement would be most concerning?

I can't believe my partner actually left the room.

The nurse is conducting an assessment of a client in a same-sex relationship who shows signs of physical injuries and reports being afraid to go home. Which action should the nurse take first?

Complete a thorough physical assessment, documenting all injuries and their characteristics.

A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my spouse. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would be best?

Low self-esteem related to lack of confidence in ability.

What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

What would you like me to know?

A female client and their partner come to the emergency department. The client has bruising on both upper extremities and a fracture of the left arm. The client states that they fell down the stairs. What finding would lead the nurse to suspect that the client is a victim of violence?

Partner states that client is very clumsy and accident prone.

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.

A nurse is caring for a client who is a victim of intimate partner violence. The nurse determines further education is required regarding a safety plan when the client makes which of the following statements?

I feel uncomfortable asking the neighbors to call the police when they hear a disturbance at my house.

A client who is a victim of intimate partner violence is planning to leave the abusive partner. What is the best response by the nurse?

"Do you have a plan?"

A nurse is assessing an older adult client who may be a victim of elder mistreatment. Which of the following are examples of elder mistreatment? Select all that apply.

Failure to provide adequate nutrition to an older adult

Shoving an older adult into a wheelchair

Forcing an older adult to perform a sexual act

Having an older adult sign financial documents without an understanding of what is being signed