A nurse is interviewing a child who is suspected of being abused. Which of the following would be most appropriate? • Ask questions that are highly detailed. • Use direct, nonleading questions. • Offer the child a reward for answering questions. • Use simple yes and no questions regardless of the child's age. • The nurse is assisting a female patient who has been physically abused about a safety plan. The patient prefers to return home. Which of the following would the nurse need to do first? • Have the patient complete a danger assessment. • Notify the neighbors about the abuse. • Tell her to have her bags packed. • Give the patient the number of a shelter. • An emergency department nurse asks a patient to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment? • ìWe are required by law to ask you these questions.î • ìWe routinely screen everyone because violence affects so many people.î • ìWe don't think you're abused but we have to ask.î • ìThis is just something we need to do for reimbursement.î • A woman and her partner come to the emergency department. The woman has bruising on both upper extremities and a fracture of the left arm. The patient states that she fell down the stairs. Which of the following would lead the nurse to suspect that the patient is a victim of violence? • patient freely answers questions asked about the injury • Partner states that patient is very clumsy and accident prone • Partner offers to leave the examination room • patient holds partner's hand when arm is being examined • When assessing an older adult about possible mistreatment, which of the following questions would be most appropriate to use initially? • ìHave you ever been abused?î • ìDid you ever sign papers you didn't understand?î • ìWhat is a typical day in your life like?î • ìAre you alone often at home?î • A victim of intimate partner violence tells a nurse, ìI don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager.î When developing the plan of care for this patient, which nursing diagnosis would most likely apply? • Anxiety related to the physical escalation of the violence • Impaired parenting related to family violence • Low self-esteem related to lack of confidence in ability • Risk for violence related to inadequate coping abilities • When preparing a discussion about violence, which of the following would the nurse include? • Abuse is primarily limited to lower socioeconomic groups. • Family violence is a public health problem. • Males experiencing intimate partner abuse have more options for help. • Several states now require the reporting of child abuse. • A pediatric nurse is assessing a 7-year-old boy who is suspected of being the victim of psychological abuse by his stepfather. What criterion would the nurse use to determine whether the stepfather's actions constitute abuse? • The behavior is a threat to the child's well-being. • The child expresses a dislike for his stepfather. • The behavior is not aimed at fostering the boy's growth and development. • The child states that he gets punished if he does not behave appropriately. • A 36-year-old woman has been a patient of a fertility clinic for 2 years and has now scheduled an appointment, believing that she is pregnant. The nurse who provides care at the clinic should screen the woman for intimate partner violence (IPV) at what time? • During the woman's first prenatal visit to the clinic • As soon as an appointment can be scheduled with the woman's partner • At a point when the woman states she is comfortable with being screened • Once the woman begins her second trimester of pregnancy • A nurse is admitting a 30-year-old female patient and recognizes the need to screen the patient for abuse. Prior to doing so, the nurse should do which of the following? • Ensure a private setting. • Perform a physical assessment. • Have the patient sign an informed consent form. • Teach the patient about intimate partner violence (IPV). • A nurse on a medical unit is reviewing a patient's electronic health record. What finding should suggest to the nurse that the patient has a possible history of intimate partner violence? • Documentation of an incomplete immunization history • A documented history of bipolar disorder • A lack of consistent primary health care during her pregnancies • Documentation of three separate injuries during her pregnancies • The nurse recognizes the need to screen a middle-aged patient for intimate partner violence, but the patient's partner is remaining close to the patient. As a result, the nurse is unable to screen the patient in privacy. What action should the nurse next take? • Document the fact that the patient is suspected of being a victim of IPV. • Prioritize the results of the physical assessment. • Closely observe the patient's interactions with the partner. • Assess the patient's psychosocial status and mental status. • A patient tearfully admits to the nurse that her husband beats her when he drinks alcohol excessively. How should the nurse best respond to the patient's statement? • ìThank you for implicating your husband in this illegal behavior.î • ìIt took a great deal of courage for you to tell me that.î • ìI will take action to make sure that this never happens again.î • ìNow that this is out in the open, you can begin to rebuild your life.î • The nurse is examining a 4-year-old girl who is being treated for a burn. When determining whether the burn may be the result of abuse, what assessment parameters should the nurse consider? Select all that apply. • The presence of other scars on the child's skin • The pattern or shape of the burn • The location of the burn • The child's explanation of how she got the burn • The child's prognosis for recovering from the burn • The nurse has completed an assessment of a 36-year-old woman who was assaulted by her boyfriend. The nurse should ensure that documentation is particularly detailed and accurate for what reason? • The nurse's scope of practice requires extensive documentation. • The nurse's documentation may be used as legal evidence. • The documentation must be validated with the patient. • The nurse's documentation must be notarized once it is complete. • The nurse has completed the objective and subjective assessment of a patient who required care after an incident of intimate partner violence. How should the nurse document the patient's injuries? • Ask the patient to write out a description of his or her injuries. • Describe the location of the injuries in detailed prose. • Make a video recording of the patient's skin surfaces. • Document using an injury map. • A middle-aged patient with a periorbital hematoma admits to the nurse that the injury occurred when her husband punched her in a rage. Following assessment and treatment, the patient expresses her intention to return home to her husband. How should the nurse best respond? • Remind the patient that she waives her right to press charges if she willingly returns home. • Inform the patient that she will not be permitted to return to a known unsafe setting. • Remind the patient of the threat to her safety and of her options for shelter. • Inform the patient that a social worker must grant permission for her to return home.The nurse is interviewing a female Hispanic patient who is scheduled for a cardiovascular education program. The patient states, ìI can't eat and I don't sleep because my daughter left to return to Mexico. I am sad and nervous. I need rest.î The nurse suspects that she is suffering from susto. Which action by the nurse would be best? • Give her a multivitamin supplement. • Encourage her to exercise. • Reschedule the education program. • Refer her to a counselor. • A nurse is admitting a patient who is from another culture. Prior to caring for a patient from another culture, the nurse should place primary importance on which action? • Examining personal biases and prejudices • Researching characteristics of the specific culture • Asking colleagues about ways to approach the patient • Developing awareness of the culture's health practices • A nurse educator is leading a group of nurses in exercises aimed at improving cultural competence. Which of the following would the educator use to best describe an aspect of the term ìcultureî? • Transmission occurs to another generation through genetics. • It is shared through norms for behaviors, values, and beliefs. • It is adapted to a specific environment. • It is experienced by all people even without human contact. • A nurse states, ìHispanic people have no clue about primary prevention of illness.î The nurse is demonstrating which of the following? • Stereotyping • Ethnicity • Cultural incompetence • Prejudice • A nurse is assessing a patient of East Asian descent. Which biological variation would the nurse expect? • Dry cerumen in the patient's ears • Profuse perspiration in the patient's axillary area • Strong body odor • Longer eustachian tubes • A nurse who provides care in a busy, inner-city clinic performs physical examinations on patients of various cultures. In a patient from which group would the nurse expect to find the greatest amount of body odor from perspiration? • Inuit • Asian • Caucasian • Native American • An African-American woman collapses at the funeral of her mother and later states that she could hear everything people were saying to her but, for a brief period, she could not move. The nurse interprets this as which of the following? • Spell • Falling out • Empacho • Susto