Chapter 07: Domestic and Family Violence Assessments My Nursing Test Banks

Chapter 07: Domestic and Family Violence Assessments

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities?

a.

Statements from the victim

b.

Statements from witnesses

c.

Proof of abuse and/or neglect

d.

Suspicion of elder abuse and/or neglect

ANS: D

Many health care workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only the suspicion of elder abuse or neglect is necessary.

DIF: Cognitive Level: Applying (Application) REF: p. 104

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

2. During a home visit, the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. This situation is best described by the term:

a.

Physical abuse.

b.

Financial neglect.

c.

Psychological abuse.

d.

Unintentional physical neglect.

ANS: D

Unintentional physical neglect may occur, despite good intentions, and is the failure of a family member or caregiver to provide basic goods or services. Physical abuse is defined as violent acts that result or could result in injury, pain, impairment, or disease. Financial neglect is defined as the failure to use the assets of the older person to provide services needed by him or her. Psychological abuse is defined as behaviors that result in mental anguish.

DIF: Cognitive Level: Applying (Application) REF: p. 105

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

3. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation?

a.

When IPV is suspected

b.

When a woman has an unexplained injury

c.

As a routine part of each health care encounter

d.

When a history of abuse in the family is known

ANS: C

Many nursing professional organizations have called for routine, universal screening for IPV to assist women in getting help for the problem.

DIF: Cognitive Level: Applying (Application) REF: p. 105

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

4. Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen?

a.

We are required by law to ask these questions.

b.

We need to talk about whether you believe you have been abused.

c.

We are asking these questions because we suspect that you are being abused.

d.

We need to ask the following questions because domestic violence is so common in our society.

ANS: D

Such an introduction alerts the woman that questions about domestic violence are coming and ensures the woman that she is not being singled out for these questions.

DIF: Cognitive Level: Applying (Application) REF: p. 106

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

5. Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface?

a.

Abrasion

b.

Contusion

c.

Laceration

d.

Hematoma

ANS: C

The term laceration refers to a wound produced by the tearing or splitting of body tissue. An abrasion is caused by the rubbing of the skin or mucous membrane. A contusion is injury to tissues without breakage of skin, and a hematoma is a localized collection of extravasated blood.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 108

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

6. During an examination, the nurse notices a patterned injury on a patients back. Which of these would cause such an injury?

a.

Blunt force

b.

Friction abrasion

c.

Stabbing from a kitchen knife

d.

Whipping from an extension cord

ANS: D

A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin or organ. The other actions do not cause a patterned injury.

DIF: Cognitive Level: Applying (Application) REF: p. 109

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

7. When documenting IPV and elder abuse, the nurse should include:

a.

Photographic documentation of the injuries.

b.

Summary of the abused patients statements.

c.

Verbatim documentation of every statement made.

d.

General description of injuries in the progress notes.

ANS: A

Documentation of IPV and elder abuse must include detailed nonbiased progress notes, the use of injury maps, and photographic documentation. Written documentation needs to be verbatim, within reason. Not every statement can be documented.

DIF: Cognitive Level: Applying (Application) REF: p. 110

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

8. A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse has noticed some other conditions that are associated with IPV. Examples of such conditions include:

a.

Asthma.

b.

Confusion.

c.

Depression.

d.

Frequent colds.

ANS: C

Depression is one of the conditions that is particularly associated with IPV. Abused women also have been found to have more chronic health problems, such as neurologic, gastrointestinal, and gynecologic symptoms; chronic pain; and symptoms of suicidality and posttraumatic stress disorder.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 106

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

9. The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of these statements best describes its use?

a.

The DA tool is to be administered by law enforcement personnel.

b.

The DA tool should be used in every assessment of suspected abuse.

c.

The number of yes answers indicates the womans understanding of her situation.

d.

The higher the number of yes answers, the more serious the danger of the womans situation.

ANS: D

No predetermined cutoff scores exist on the DA. The higher the number yes answers, the more serious the danger of the womans situation. The use of this tool is not limited to law enforcement personnel and is not required in every case of suspected abuse.

DIF: Cognitive Level: Applying (Application) REF: p. 112

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

10. The nurse is assessing bruising on an injured patient. Which color indicates a new bruise that is less than 2 hours old?

a.

Red

b.

Purple-blue

c.

Greenish-brown

d.

Brownish-yellow

ANS: A

A new bruise is usually red and will often develop a purple or purple-blue appearance 12 to 36 hours after blunt-force trauma. The color of bruises (and ecchymoses) generally progresses from purple-blue to bluish-green to greenish-brown to brownish-yellow before fading away.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 108

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

11. The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. The best way to document the history and physical findings is to:

a.

Document what the childs caregiver tells the nurse.

b.

Use the words the child has said to describe how the injury occurred.

c.

Record what the nurse observes during the conversation.

d.

Rely on photographs of the injuries.

ANS: B

When documenting the history and physical findings of suspected child abuse and neglect, use the words the child has said to describe how his or her injury occurred. Remember, the abuser may be accompanying the child.

DIF: Cognitive Level: Applying (Application) REF: p. 108

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. During an interview, a woman has answered yes to two of the Abuse Assessment Screen questions. What should the nurse say next?

a.

I need to report this abuse to the authorities.

b.

Tell me about this abuse in your relationship.

c.

So you were abused?

d.

Do you know what caused this abuse?

ANS: B

If a woman answers yes to any of the Abuse Assessment Screen questions, then the nurse should ask questions designed to assess how recent and how serious the abuse was. Asking the woman an open-ended question, such as tell me about this abuse in your relationship is a good way to start.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 106

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. The nurse is examining a 3-year-old child who was brought to the emergency department after a fall. Which bruise, if found, would be of most concern?

a.

Bruise on the knee

b.

Bruise on the elbow

c.

Bruising on the abdomen

d.

Bruise on the shin

ANS: C

Studies have shown that children who are walking often have bruises over the bony prominences of the front of their bodies. Other studies have found that bruising in atypical places such as the buttocks, hands, feet, and abdomen were exceedingly rare and should arouse concern.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 109

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. The nurse assesses an older woman and suspects physical abuse. Which questions are appropriate for screening for abuse? Select all that apply.

a.

Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

b.

Are you being abused?

c.

Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

d.

Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

e.

Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

ANS: A, C, D, E

Directly asking Are you being abused? is not an appropriate screening question for abuse because the woman could easily say no, and no further information would be obtained. The other questions are among the questions recommended by the Elder Abuse Suspicion Index (EASI) when screening for elder abuse.

DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 103-104

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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