A female patient with bone cancer is experiencing pain that has become more severe over the past several days. When modifying the patient's plan of care, the nurse identifies a need to assess the affective dimension of the patient's pain. How can the nurse best accomplish this goal? • Document the ways that the patient's pain affects her activities of daily living. • Determine whether the patient is able to independently treat her pain.• Closely monitor the effects of the patient's pain on her emotions. • Ask the patient to rate her pain during every physiological assessment. • A nurse is attempting to apply the principles of cultural competency in the care of a 72- year-old Asian-American woman who has a spinal cord compression. Which of the following statements should guide the nurse's care? • The patient may view pain as a sign of weak character. • The patient may be reluctant to accept opioids. • The patient may tend to overreport her pain. • The patient may be unable to understand quantitative assessment scales. • A female patient with advanced-stage vascular dementia has been showing signs of pain over the past several hours. The nurse is unable to obtain a self-report from the patient due to her cognitive impairment. When applying the Hierarchy of Pain Assessment Techniques, how should the nurse proceed with assessment? • Search for potential causes of pain. • Ask the patient's family if they believe she is in pain. • Perform interventions as if the patient were in pain. • Use a visual assessment tool rather than a verbal tool. • A nurse is admitting a patient to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the patient from the stretcher to a bed and asked the patient if he is experiencing pain. The patient acknowledges that he is in pain. What should be the nurse's next action? • Ask the patient to briefly explain his cultural background. • Assess the patient's pain according to COLDSPA. • Assess the patient's self-management skills. • Assess the patient's pain by obtaining a set of vital signs. • A nurse is providing care to a patient who has been in a motor vehicle accident and who has facial lacerations and a pelvic fracture. How can the nurse best determine the reliability and accuracy of data obtained during a pain assessment? • Ask the primary care provider to validate the assessment data. • Compare the findings to the patient's preinjury level of health. • Compare the findings to the most recent previous pain assessment. • Validate the assessment data with the patient. • A nurse is performing a detailed pain assessment of a patient who has sought care for debilitating migraines. When assessing for precipitating factors, what question should the nurse ask? • ìIs there anything that's given you relief in the past?î • ìHave your migraines gotten more severe in the last few months?î • ìWhat were you doing immediately before your last migraine?î • ìHow long does a typical migraine last?î • An older adult patient with osteoarthritis has tearfully admitted to the nurse that she is no longer able to climb the stairs to the second floor of her house due to her knee pain. What nursing diagnosis is suggested by this patient's statement? • Ineffective coping related to knee pain • Activity intolerance related to knee pain • Ineffective role performance related to osteoarthritis • Situational low self-esteem related to osteoarthritis A nurse is preparing a presentation for a local community group on family violence and child abuse. Which of the following would be most appropriate for the nurse to research when defining child abuse in legal terms? • The Prevent Child Abuse America group • The Child Abuse Prevention and Treatment Act • The Child Abuse Prevention Network • The Child Well-being and Domestic Violence Project • The nurse in a prenatal clinic is performing an assessment on a pregnant patient. When it is noted that clumps of hair are missing from the patient's scalp, the nurse should ask what assessment question? • ìHave you ever been the victim of a crime?î • ìWhat do you know about the problem of domestic violence?î • ìDo you feel safe in your home setting?î • ìCan you tell me if anyone recent attacked you?î • A group of community nurses are reviewing the theories associated with abuse. The nurses are addressing the psychopathology theory when they identify that violence results from which of the following? • The abuser's need to control others • The abuser's desire to show authority • The abuser's need to be in charge • The abuser's personality disorder • While the nurse is interviewing a patient who is a victim of abuse, the patient states that she blames herself for not satisfying her husband's demands. Applying Walker's Cycle of Violence theory, the patient would be in which of the following phase? • Tension-building phase • Acute battering phase • Honeymoon phase • Reconciliation phase • A nurse is preparing to discuss the cycle of violence with a group of women who have been victims of abuse. Which of the following would the nurse include as part of phase 3 of this cycle? • A reconciliation period • Shoving and slapping • Victim separation from support group • Acute battering • A nurse is preparing a program to address family violence prevention. Which of the following would be most important for the nurse to incorporate into the program? • Children raised with intimate partner violence are more likely to use violence as adults. • One out of ten women who are pregnant often fall victim to intimate partner violence. • Victims of abuse account for approximately 2,500 visits to their health care providers yearly. • Abuse is most commonly perpetrated by people with low levels of education. • Which of the following would the nurse do first when collecting subjective data from a patient when domestic violence is suspected? • Discuss legal reporting requirements. • Talk about limits of confidentiality. • Create a safe environment. • Have a witness to the conversation. • When assessing a patient for possible abuse, which of the following would most likely suggest that the patient is a victim of abuse? • Repeated emergency department visits for injuries • Poor or no prenatal care • History of alcohol abuse • Failure to gain weight in pregnancy • The nurse has identified that a female patient desires to leave her abusive husband and move with her children to her parents' house. Which of the following would be the most appropriate nursing diagnosis? • Readiness for enhanced family processes • Grieving related to loss of ideal relationship • Disturbed personal identity related to moving to parent's house • Impaired parenting related to loss of relationship • A group of students is reviewing the events associated with the cycle of violence. Which statement by the students demonstrates understanding of the topic? • It occurs in a predictable pattern. • There are five phases in the cycle. • During phase 2, the victim can often stop the abuser. • Criticism is the defining part of phase 3. • A new graduate nurse asks a clinical nurse educator, ìI know abuse is a problem, but why must we screen all women during routine health contacts for potential abuse?î Which response by the more experienced nurse would be most appropriate? • ìThe Family Violence Prevention Fund mandates it.î • ìConsistent risk factors for women at risk have not been identified.î • ìWomen who are being abused always try to hide the fact.î • ìThe abuse is typically part of the presenting problem.î • Which of the following principles should inform the nurse's practice when assessing a patient for possible physical abuse? • The abuse is usually part of the patient's presenting health problem. • Physical abuse is thought to occur in about 5% of women. • Abuse may start at any time during a relationship. • Abuse rarely occurs in women younger than age 25 years. • A nurse is interviewing a patient who is a suspected victim of abuse. Which of the following practices should the nurse avoid during this phase of assessment? • Using direct questions about being injured • Displaying a concerned, empathetic approach • Interjecting often to clarify information • Emphasizing the nurse's availability to talk • 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