Chapter 24 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 24

Question 1

Type: MCSA

A client with a poorly regulated corticotropin-releasing factor (CRF) will most likely have difficulties:

1. Relating to others.

2. Coping with stress.

3. Balancing life issues.

4. Interpreting the environment.

Correct Answer: 2

Rationale 1: Instability in the way CRF performs its function makes it more difficult for adults to cope with stress. CRF is a major regulator of the endocrine, autonomic, immune, and behavioral stress responses. CRF is not associated with difficulties in relationships, maintaining a balanced life, or interpreting the environment.

Rationale 2: Instability in the way CRF performs its function makes it more difficult for adults to cope with stress. CRF is a major regulator of the endocrine, autonomic, immune, and behavioral stress responses. CRF is not associated with difficulties in relationships, maintaining a balanced life, or interpreting the environment.

Rationale 3: Instability in the way CRF performs its function makes it more difficult for adults to cope with stress. CRF is a major regulator of the endocrine, autonomic, immune, and behavioral stress responses. CRF is not associated with difficulties in relationships, maintaining a balanced life, or interpreting the environment.

Rationale 4: Instability in the way CRF performs its function makes it more difficult for adults to cope with stress. CRF is a major regulator of the endocrine, autonomic, immune, and behavioral stress responses. CRF is not associated with difficulties in relationships, maintaining a balanced life, or interpreting the environment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the biopsychosocial causes of intrafamily physical abuse and intrafamily sexual abuse.

Question 2

Type: MCSA

The nurse understands that the underlying issue of most abusers is:

1. An uncontrollably urge to love.

2. The inability to control intense anxiety.

3. A desire to enslave and control.

4. A desire to play out fantasies.

Correct Answer: 3

Rationale 1: The abuser is the most powerful person in the life of the abused. The abusers purpose is to enslave the victim, while simultaneously demanding respect, gratitude, and love. Control over the victim is established by repetitive emotional abuse that instills terror and helplessness. Threats of serious harm or threats against other family members keep the victim in a constant state of fear.

Rationale 2: The abuser is the most powerful person in the life of the abused. The abusers purpose is to enslave the victim, while simultaneously demanding respect, gratitude, and love. Control over the victim is established by repetitive emotional abuse that instills terror and helplessness. Threats of serious harm or threats against other family members keep the victim in a constant state of fear.

Rationale 3: The abuser is the most powerful person in the life of the abused. The abusers purpose is to enslave the victim, while simultaneously demanding respect, gratitude, and love. Control over the victim is established by repetitive emotional abuse that instills terror and helplessness. Threats of serious harm or threats against other family members keep the victim in a constant state of fear.

Rationale 4: The abuser is the most powerful person in the life of the abused. The abusers purpose is to enslave the victim, while simultaneously demanding respect, gratitude, and love. Control over the victim is established by repetitive emotional abuse that instills terror and helplessness. Threats of serious harm or threats against other family members keep the victim in a constant state of fear.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the biopsychosocial causes of intrafamily physical abuse and intrafamily sexual abuse.

Question 3

Type: MCSA

Domestic violence is often associated with:

1. High school dropouts.

2. The poor and undereducated.

3. Blue-collar workers.

4. All levels of society.

Correct Answer: 4

Rationale 1: Domestic violenceviolence within the familyoccurs at all levels of society. The myth is that violence occurs only among the poor and undereducated; the reality is that violence also occurs among the middle and upper classes as well as the professional elite. In the past, these problems among wealthy or prominent people were kept hidden from the general public. With an increase in national concern, however, more publicity is being given to cases of domestic violence at all socioeconomic levels.

Rationale 2: Domestic violenceviolence within the familyoccurs at all levels of society. The myth is that violence occurs only among the poor and undereducated; the reality is that violence also occurs among the middle and upper classes as well as the professional elite. In the past, these problems among wealthy or prominent people were kept hidden from the general public. With an increase in national concern, however, more publicity is being given to cases of domestic violence at all socioeconomic levels.

Rationale 3: Domestic violenceviolence within the familyoccurs at all levels of society. The myth is that violence occurs only among the poor and undereducated; the reality is that violence also occurs among the middle and upper classes as well as the professional elite. In the past, these problems among wealthy or prominent people were kept hidden from the general public. With an increase in national concern, however, more publicity is being given to cases of domestic violence at all socioeconomic levels.

Rationale 4: Domestic violenceviolence within the familyoccurs at all levels of society. The myth is that violence occurs only among the poor and undereducated; the reality is that violence also occurs among the middle and upper classes as well as the professional elite. In the past, these problems among wealthy or prominent people were kept hidden from the general public. With an increase in national concern, however, more publicity is being given to cases of domestic violence at all socioeconomic levels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the biopsychosocial causes of intrafamily physical abuse and intrafamily sexual abuse.

Question 4

Type: MCSA

During an education session, a community member asks what causes domestic violence. The best response is:

1. The statistics indicate that it is caused by poverty.

2. It is caused by the demanding workload of either parent.

3. The police commissioner can provide complete and accurate data on the causes.

4. There is no single cause of this type of violence.

Correct Answer: 4

Rationale 1: Domestic violence results from an interaction of neurobiological, personality, situational, and societal factors that have an impact on families. Domestic violence occurs at all levels of income and education and is not necessarily caused by overworked parents. Data provided by a police commissioner would not address causes. A demanding workload may be a contributor, but it is not the sole cause of domestic violence.

Rationale 2: Domestic violence results from an interaction of neurobiological, personality, situational, and societal factors that have an impact on families. Domestic violence occurs at all levels of income and education and is not necessarily caused by overworked parents. Data provided by a police commissioner would not address causes. A demanding workload may be a contributor, but it is not the sole cause of domestic violence.

Rationale 3: Domestic violence results from an interaction of neurobiological, personality, situational, and societal factors that have an impact on families. Domestic violence occurs at all levels of income and education and is not necessarily caused by overworked parents. Data provided by a police commissioner would not address causes. A demanding workload may be a contributor, but it is not the sole cause of domestic violence.

Rationale 4: Domestic violence results from an interaction of neurobiological, personality, situational, and societal factors that have an impact on families. Domestic violence occurs at all levels of income and education and is not necessarily caused by overworked parents. Data provided by a police commissioner would not address causes. A demanding workload may be a contributor, but it is not the sole cause of domestic violence.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the biopsychosocial causes of intrafamily physical abuse and intrafamily sexual abuse.

Question 5

Type: MCSA

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?

1. High Risk for Violence

2. Self-Esteem Disturbance

3. Alteration in Health Maintenance

4. Powerlessness

Correct Answer: 4

Rationale 1: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience Health Maintenance problems because of the experienced domestic violence, however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their life. The client is not at high risk to express violence, but is rather at high risk to experience it.

Rationale 2: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience Health Maintenance problems because of the experienced domestic violence, however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their life. The client is not at high risk to express violence, but is rather at high risk to experience it.

Rationale 3: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience Health Maintenance problems because of the experienced domestic violence, however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their life. The client is not at high risk to express violence, but is rather at high risk to experience it.

Rationale 4: Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience Health Maintenance problems because of the experienced domestic violence, however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their life. The client is not at high risk to express violence, but is rather at high risk to experience it.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Discuss the short-term and long-term effects on victims of intrafamily violence.

Question 6

Type: MCSA

Which of the following combinations of clinical presentations constitutes the most compelling indication that a client may have been abused?

1. Poor eye contact, depressed mood, unwillingness to give history data

2. Multiple bruises and scars, low self-esteem

3. Acting-out behaviors, disobedience, trouble with the law

4. Sores around the mouth, brittle hair

Correct Answer: 2

Rationale 1: Physical abuse is the non-accidental use of physical force that results in bodily injury, pain, or impairment. Multiple bruises, scars at various levels of healing, and low self-esteem are signs that the client may have been subjected to physical abuse and humiliation. Acting-out behaviors are more consistent with antisocial personality disorder. Poor eye contact and other withdrawn behaviors are more consistent with a diagnosis of depression. Sores around the mouth may indicate an eating disorder.

Rationale 2: Physical abuse is the non-accidental use of physical force that results in bodily injury, pain, or impairment. Multiple bruises, scars at various levels of healing, and low self-esteem are signs that the client may have been subjected to physical abuse and humiliation. Acting-out behaviors are more consistent with antisocial personality disorder. Poor eye contact and other withdrawn behaviors are more consistent with a diagnosis of depression. Sores around the mouth may indicate an eating disorder.

Rationale 3: Physical abuse is the non-accidental use of physical force that results in bodily injury, pain, or impairment. Multiple bruises, scars at various levels of healing, and low self-esteem are signs that the client may have been subjected to physical abuse and humiliation. Acting-out behaviors are more consistent with antisocial personality disorder. Poor eye contact and other withdrawn behaviors are more consistent with a diagnosis of depression. Sores around the mouth may indicate an eating disorder.

Rationale 4: Physical abuse is the non-accidental use of physical force that results in bodily injury, pain, or impairment. Multiple bruises, scars at various levels of healing, and low self-esteem are signs that the client may have been subjected to physical abuse and humiliation. Acting-out behaviors are more consistent with antisocial personality disorder. Poor eye contact and other withdrawn behaviors are more consistent with a diagnosis of depression. Sores around the mouth may indicate an eating disorder.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Discuss the short-term and long-term effects on victims of intrafamily violence.

Question 7

Type: MCSA

When working with sibling abuse victim, the nurse should recognize that:

1. Most adults were victims of sibling abuse.

2. 40% of all child homicides are caused by sibling abuse.

3. Parents recognize and condone physical confrontation.

4. Hitting increases the probability of violence.

Correct Answer: 4

Rationale 1: Children who are hit by their parents exhibit more than double the rate of violence against siblings than children whose parents do not hit them. Hitting children increases the probability that they will be violent. Parents should not be complacent about sibling aggression; siblings cause 3% of all child homicides in the United States. Most adults in a position to know about violent confrontations and relationships (parents, faculty, police, medically trained personnel) have an awareness of sibling and peer violence that is very low.

Rationale 2: Children who are hit by their parents exhibit more than double the rate of violence against siblings than children whose parents do not hit them. Hitting children increases the probability that they will be violent. Parents should not be complacent about sibling aggression; siblings cause 3% of all child homicides in the United States. Most adults in a position to know about violent confrontations and relationships (parents, faculty, police, medically trained personnel) have an awareness of sibling and peer violence that is very low.

Rationale 3: Children who are hit by their parents exhibit more than double the rate of violence against siblings than children whose parents do not hit them. Hitting children increases the probability that they will be violent. Parents should not be complacent about sibling aggression; siblings cause 3% of all child homicides in the United States. Most adults in a position to know about violent confrontations and relationships (parents, faculty, police, medically trained personnel) have an awareness of sibling and peer violence that is very low.

Rationale 4: Children who are hit by their parents exhibit more than double the rate of violence against siblings than children whose parents do not hit them. Hitting children increases the probability that they will be violent. Parents should not be complacent about sibling aggression; siblings cause 3% of all child homicides in the United States. Most adults in a position to know about violent confrontations and relationships (parents, faculty, police, medically trained personnel) have an awareness of sibling and peer violence that is very low.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss the short-term and long-term effects on victims of intrafamily violence.

Question 8

Type: MCMA

A 10-year-old is brought to the clinic for assessment. During the interview, the nurse learns that the child has been the victim of domestic violence. Which of the following messages would the nurse expect to hear in the assessment of the child due to the childs experience of abuse?

Standard Text: Select all that apply.

1. It is appropriate to love the people you hit.

2. Violence does not resolve conflict.

3. If you are small and weak, you deserve to be hit.

4. Violence is appropriate if the end result is good.

5. People who love you dont hit you.

Correct Answer: 3,4

Rationale 1: Acts of violence against children range from a light slap to a severe beating to homicide. In some families or cultures, hitting or spanking children is condoned and even approved as being necessary and good for the child. Many parents, however, do not realize the underlying messages they are giving the child by hitting.

Rationale 2: Acts of violence against children range from a light slap to a severe beating to homicide. In some families or cultures, hitting or spanking children is condoned and even approved as being necessary and good for the child. Many parents, however, do not realize the underlying messages they are giving the child by hitting.

Rationale 3: Acts of violence against children range from a light slap to a severe beating to homicide. In some families or cultures, hitting or spanking children is condoned and even approved as being necessary and good for the child. Many parents, however, do not realize the underlying messages they are giving the child by hitting.

Rationale 4: Acts of violence against children range from a light slap to a severe beating to homicide. In some families or cultures, hitting or spanking children is condoned and even approved as being necessary and good for the child. Many parents, however, do not realize the underlying messages they are giving the child by hitting.

Rationale 5: Acts of violence against children range from a light slap to a severe beating to homicide. In some families or cultures, hitting or spanking children is condoned and even approved as being necessary and good for the child. Many parents, however, do not realize the underlying messages they are giving the child by hitting.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Discuss the short-term and long-term effects on victims of intrafamily violence.

Question 9

Type: MCSA

An older client comes to the health center with vague complaints of abdominal discomfort. Assessment findings include several old and fresh bruises in the abdominal area, and signs of malnutrition. What is the most appropriate question for the nurse to ask?

1. Are you dieting?

2. Did you have any falls lately?

3. Do you have an alcohol problem?

4. Did anyone hurt you?

Correct Answer: 4

Rationale 1: When the nurse suspects abuse, it is important to ask direct questions, such as asking if the client has been hurt by someone. Asking if the client is dieting or has fallen implies that the nurse has made assumptions about the cause of the injuries. An older client, fearful of further abuse, may agree to these suggestions in order to cover up abuse. The question about an alcohol problem carries with it a suggestion that the client is to blame for the injuries.

Rationale 2: When the nurse suspects abuse, it is important to ask direct questions, such as asking if the client has been hurt by someone. Asking if the client is dieting or has fallen implies that the nurse has made assumptions about the cause of the injuries. An older client, fearful of further abuse, may agree to these suggestions in order to cover up abuse. The question about an alcohol problem carries with it a suggestion that the client is to blame for the injuries.

Rationale 3: When the nurse suspects abuse, it is important to ask direct questions, such as asking if the client has been hurt by someone. Asking if the client is dieting or has fallen implies that the nurse has made assumptions about the cause of the injuries. An older client, fearful of further abuse, may agree to these suggestions in order to cover up abuse. The question about an alcohol problem carries with it a suggestion that the client is to blame for the injuries.

Rationale 4: When the nurse suspects abuse, it is important to ask direct questions, such as asking if the client has been hurt by someone. Asking if the client is dieting or has fallen implies that the nurse has made assumptions about the cause of the injuries. An older client, fearful of further abuse, may agree to these suggestions in order to cover up abuse. The question about an alcohol problem carries with it a suggestion that the client is to blame for the injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish who is at greatest risk for intrafamily physical and sexual abuse.

Question 10

Type: MCSA

A nurse is taking the history of a client and suspects that the client has been sexually abused. Which question will prompt a response that will aid the nurse in making an accurate assessment?

1. Do you like to dress in provocative outfits?

2. Has anyone touched you in a way that made you feel uneasy or uncomfortable?

3. Do you have any bruises anywhere on your body?

4. How is your relationship with your parents and older siblings?

Correct Answer: 2

Rationale 1: It is important to ask directly whether the client has been made uneasy or uncomfortable, as this would indicate that further assessment is necessary. The other answers express personal biases about the cause of abuse and the identity of the abuser, or are vague as they can fit scenarios that may have nothing to do with abuse.

Rationale 2: It is important to ask directly whether the client has been made uneasy or uncomfortable, as this would indicate that further assessment is necessary. The other answers express personal biases about the cause of abuse and the identity of the abuser, or are vague as they can fit scenarios that may have nothing to do with abuse.

Rationale 3: It is important to ask directly whether the client has been made uneasy or uncomfortable, as this would indicate that further assessment is necessary. The other answers express personal biases about the cause of abuse and the identity of the abuser, or are vague as they can fit scenarios that may have nothing to do with abuse.

Rationale 4: It is important to ask directly whether the client has been made uneasy or uncomfortable, as this would indicate that further assessment is necessary. The other answers express personal biases about the cause of abuse and the identity of the abuser, or are vague as they can fit scenarios that may have nothing to do with abuse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish who is at greatest risk for intrafamily physical and sexual abuse.

Question 11

Type: MCSA

Who is at greatest risk for becoming the victim of intrafamily violence?

1. The child who has a stepfather

2. The male child

3. The child born out of an unplanned pregnancy

4. The child living in a home in which a parent is being abused

Correct Answer: 4

Rationale 1: Children who live in a home in which a parent is being abused are 1500 times more likely to be abused than the national average. Children born of an unplanned pregnancy, male children, and children with stepfathers are at lower risk of violence than those who live in homes in which a parent is abused.

Rationale 2: Children who live in a home in which a parent is being abused are 1500 times more likely to be abused than the national average. Children born of an unplanned pregnancy, male children, and children with stepfathers are at lower risk of violence than those who live in homes in which a parent is abused.

Rationale 3: Children who live in a home in which a parent is being abused are 1500 times more likely to be abused than the national average. Children born of an unplanned pregnancy, male children, and children with stepfathers are at lower risk of violence than those who live in homes in which a parent is abused.

Rationale 4: Children who live in a home in which a parent is being abused are 1500 times more likely to be abused than the national average. Children born of an unplanned pregnancy, male children, and children with stepfathers are at lower risk of violence than those who live in homes in which a parent is abused.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish who is at greatest risk for intrafamily physical and sexual abuse.

Question 12

Type: MCSA

Who among the following females is at greatest risk of becoming a victim of sexual abuse?

1. A female who carpools with a male coworker

2. The partner of a man with a strong sex drive

3. An attractive 14-year-old female who dresses in a manner that makes her appear older

4. A 45-year-old widow who goes to a local club to meet new people

Correct Answer: 1

Rationale 1: Sexual abuse occurs in all ethnic, religious, economic, and cultural subgroups. Affinity systemsimmediate family, relatives, friends, neighbors, clergy, scout leadersaccount for 75% to 90% of the abusers. Male perpetrators are involved in 90% of reported cases. Although fatherdaughter incest is most reported, it is believed that sibling incest is the most widespread. Some siblings turn to each other for emotional nurturance and acceptance. In other instances a sibling uses coercion or violence to perpetrate the abuse. More than 41% of sexual assaults occurred in or near the victims home and 41% of sexual assaults were reported to law enforcement.

Rationale 2: Sexual abuse occurs in all ethnic, religious, economic, and cultural subgroups. Affinity systemsimmediate family, relatives, friends, neighbors, clergy, scout leadersaccount for 75% to 90% of the abusers. Male perpetrators are involved in 90% of reported cases. Although fatherdaughter incest is most reported, it is believed that sibling incest is the most widespread. Some siblings turn to each other for emotional nurturance and acceptance. In other instances a sibling uses coercion or violence to perpetrate the abuse. More than 41% of sexual assaults occurred in or near the victims home and 41% of sexual assaults were reported to law enforcement.

Rationale 3: Sexual abuse occurs in all ethnic, religious, economic, and cultural subgroups. Affinity systemsimmediate family, relatives, friends, neighbors, clergy, scout leadersaccount for 75% to 90% of the abusers. Male perpetrators are involved in 90% of reported cases. Although fatherdaughter incest is most reported, it is believed that sibling incest is the most widespread. Some siblings turn to each other for emotional nurturance and acceptance. In other instances a sibling uses coercion or violence to perpetrate the abuse. More than 41% of sexual assaults occurred in or near the victims home and 41% of sexual assaults were reported to law enforcement.

Rationale 4: Sexual abuse occurs in all ethnic, religious, economic, and cultural subgroups. Affinity systemsimmediate family, relatives, friends, neighbors, clergy, scout leadersaccount for 75% to 90% of the abusers. Male perpetrators are involved in 90% of reported cases. Although fatherdaughter incest is most reported, it is believed that sibling incest is the most widespread. Some siblings turn to each other for emotional nurturance and acceptance. In other instances a sibling uses coercion or violence to perpetrate the abuse. More than 41% of sexual assaults occurred in or near the victims home and 41% of sexual assaults were reported to law enforcement.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish who is at greatest risk for intrafamily physical and sexual abuse.

Question 13

Type: MCSA

A psychiatric nurse is providing an educational session to the emergency room staff to raise awareness on the topic of elder abuse. Which client is most at risk for elder abuse?

1. An 82-year-old woman with middle-stage dementia

2. A 73-year-old woman living in a poor neighborhood

3. A 70-year-old man with the recent diagnosis of heart disease

4. An 89-year-old man living with a mentally ill family member

Correct Answer: 1

Rationale 1: The typical elder abuse victim is a woman of advanced age with physical and/or mental impairment who usually depends on the abuser for care. The client with dementia is the most defenseless as the result of the disease process and requires significant hands-on assistance and care. Socio-economic factors are not relevant. Elders with health-related problems are often still capable of independent living and of attending to their needs.

Rationale 2: The typical elder abuse victim is a woman of advanced age with physical and/or mental impairment who usually depends on the abuser for care. The client with dementia is the most defenseless as the result of the disease process and requires significant hands-on assistance and care. Socio-economic factors are not relevant. Elders with health-related problems are often still capable of independent living and of attending to their needs.

Rationale 3: The typical elder abuse victim is a woman of advanced age with physical and/or mental impairment who usually depends on the abuser for care. The client with dementia is the most defenseless as the result of the disease process and requires significant hands-on assistance and care. Socio-economic factors are not relevant. Elders with health-related problems are often still capable of independent living and of attending to their needs.

Rationale 4: The typical elder abuse victim is a woman of advanced age with physical and/or mental impairment who usually depends on the abuser for care. The client with dementia is the most defenseless as the result of the disease process and requires significant hands-on assistance and care. Socio-economic factors are not relevant. Elders with health-related problems are often still capable of independent living and of attending to their needs.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish who is at greatest risk for intrafamily physical and sexual abuse.

Question 14

Type: MCSA

A client with a history of physical and sexual abuse by her husband is admitted to the hospital for treatment of vaginal lacerations. While hospitalized, the client expresses concerns to the nurse about her safety when she returns home. The first priority for the nurse is to:

1. Offer to contact outpatient services if the client promises that she will not return home after her discharge.

2. Encourage the client to take charge of her situation.

3. Make it clear to the client that her husband needs to see a therapist.

4. Assist the client to devise a safety or escape plan.

Correct Answer: 4

Rationale 1: A victim of abuse by a partner should have a safety plan. This is the highest priority because the clients physical and/or mental health is in danger. The nurse should not assume that the client will be able to control her partner, and suggesting that the client tell the abusive partner to see a therapist could escalate the abuse. Encouraging a client to take charge is a very general suggestion. The client needs specific tools to develop a safety plan. It may not be safe or feasible for the client to leave home right away, and resources should not be withheld if a client is unable to promise to leave home.

Rationale 2: A victim of abuse by a partner should have a safety plan. This is the highest priority because the clients physical and/or mental health is in danger. The nurse should not assume that the client will be able to control her partner, and suggesting that the client tell the abusive partner to see a therapist could escalate the abuse. Encouraging a client to take charge is a very general suggestion. The client needs specific tools to develop a safety plan. It may not be safe or feasible for the client to leave home right away, and resources should not be withheld if a client is unable to promise to leave home.

Rationale 3: A victim of abuse by a partner should have a safety plan. This is the highest priority because the clients physical and/or mental health is in danger. The nurse should not assume that the client will be able to control her partner, and suggesting that the client tell the abusive partner to see a therapist could escalate the abuse. Encouraging a client to take charge is a very general suggestion. The client needs specific tools to develop a safety plan. It may not be safe or feasible for the client to leave home right away, and resources should not be withheld if a client is unable to promise to leave home.

Rationale 4: A victim of abuse by a partner should have a safety plan. This is the highest priority because the clients physical and/or mental health is in danger. The nurse should not assume that the client will be able to control her partner, and suggesting that the client tell the abusive partner to see a therapist could escalate the abuse. Encouraging a client to take charge is a very general suggestion. The client needs specific tools to develop a safety plan. It may not be safe or feasible for the client to leave home right away, and resources should not be withheld if a client is unable to promise to leave home.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Integrate the main principles for treating victims of violence into a treatment plan.

Question 15

Type: MCSA

What is the most therapeutic approach when caring for a client who has been the victim of domestic violence?

1. Acknowledge the clients inability to change the situation.

2. Do not ask direct questions about abuse as this will intimidate the client.

3. Invite the abuser to the assessment session.

4. Avoid pressuring the client to leave the abuser.

Correct Answer: 4

Rationale 1: It may be more dangerous for the client to leave at this time, and the client may have to wait until an opportunity arises. The client should not be discouraged from working on preventing future violence. Having the abuser present may prevent the client from talking openly to the nurse. The nurse should ask direct questions.

Rationale 2: It may be more dangerous for the client to leave at this time, and the client may have to wait until an opportunity arises. The client should not be discouraged from working on preventing future violence. Having the abuser present may prevent the client from talking openly to the nurse. The nurse should ask direct questions.

Rationale 3: It may be more dangerous for the client to leave at this time, and the client may have to wait until an opportunity arises. The client should not be discouraged from working on preventing future violence. Having the abuser present may prevent the client from talking openly to the nurse. The nurse should ask direct questions.

Rationale 4: It may be more dangerous for the client to leave at this time, and the client may have to wait until an opportunity arises. The client should not be discouraged from working on preventing future violence. Having the abuser present may prevent the client from talking openly to the nurse. The nurse should ask direct questions.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Integrate the main principles for treating victims of violence into a treatment plan.

Question 16

Type: MCSA

A client comes to the clinic complaining of headaches. Further assessment reveals three one-inch bald spots at different locations on the clients scalp. The client states the headache and the bald spots resulted from an accident. The clients partner, who has accompanied the client into the exam room, often finishes the clients sentences. The nurse should:

1. Ask the partner to remain in the waiting room while the client is examined.

2. Alert hospital security about the potential for violence.

3. Encourage the partner to remain with the client to provide information about the clients health.

4. Contact the local authorities.

Correct Answer: 1

Rationale 1: An implausible explanation for a clients injuries and a partners pattern of finishing the clients sentences should arouse the nurses suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.

Rationale 2: An implausible explanation for a clients injuries and a partners pattern of finishing the clients sentences should arouse the nurses suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.

Rationale 3: An implausible explanation for a clients injuries and a partners pattern of finishing the clients sentences should arouse the nurses suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.

Rationale 4: An implausible explanation for a clients injuries and a partners pattern of finishing the clients sentences should arouse the nurses suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Integrate the main principles for treating victims of violence into a treatment plan.

Question 17

Type: MCSA

What is the most therapeutic approach of a nurse toward a victim of violence?

1. Being supportive, nurturing, and empathetic

2. Educating the client on how to avoid future incidents

3. Distracting the client to minimize feelings of despair and guilt

4. Maintaining objectivity and offering short, to-the-point responses

Correct Answer: 1

Rationale 1: It is important for victims of violence to feel supported and cared for to develop trust and work through their issues in a therapeutic environment.

Rationale 2: It is important for victims of violence to feel supported and cared for to develop trust and work through their issues in a therapeutic environment.

Rationale 3: It is important for victims of violence to feel supported and cared for to develop trust and work through their issues in a therapeutic environment.

Rationale 4: It is important for victims of violence to feel supported and cared for to develop trust and work through their issues in a therapeutic environment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Integrate the main principles for treating victims of violence into a treatment plan.

Question 18

Type: MCSA

An appropriate ongoing, long-term treatment goal for a victim who experienced sexual abuse eight months ago is to:

1. Establish rapport and build a trusting nurseclient relationship.

2. Move from victim to survivor status.

3. Become aware of legal rights.

4. Involve significant others in the treatment plan.

Correct Answer: 2

Rationale 1: The process of moving a client from victim to survivor status may take months to years, whereas the other treatment goals can be met in the short term (hours to days).

Rationale 2: The process of moving a client from victim to survivor status may take months to years, whereas the other treatment goals can be met in the short term (hours to days).

Rationale 3: The process of moving a client from victim to survivor status may take months to years, whereas the other treatment goals can be met in the short term (hours to days).

Rationale 4: The process of moving a client from victim to survivor status may take months to years, whereas the other treatment goals can be met in the short term (hours to days).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Integrate the main principles for treating victims of violence into a treatment plan.

Question 19

Type: MCMA

A client who is being physically and sexually abused states, God doesnt want to bother with me. Am I an evil person? Why do these things always happen to me? Whats wrong with God? These statements indicate that the client is most likely experiencing:

Standard Text: Select all that apply.

1. Spiritual distress

2. Anger

3. Altered thought process

4. Fear

5. Hopelessness

Correct Answer: 1,2,4,5

Rationale 1: Spiritual distress. Victims of abuse are often plagued by spiritual questions.

Rationale 2: Anger. Victims of abuse are often consumed by anger.

Rationale 3: Altered thought process. The scenario does not indicate that the client is responding to internal stimuli.

Rationale 4: Fear. The scenario does not indicate that the client is experiencing fear.

Rationale 5: Hopelessness. Victims of abuse are often consumed by feelings of hopelessness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain why spiritual recovery is important for persons who have been victims of violence.

Question 20

Type: MCSA

In assessing a client who has suffered domestic violence, the nurse observes that the client is regressing back to childhood, is having difficulty trusting the nurse, is expressing rage and grief, and is talking about how unfair God has been and wondering why God has been so insensitive. Based on these observations, what would be the most appropriate plan of action for the nurse?

1. Suggest that the client join a survivor support group.

2. Encourage the client to attend religious activities at the local church.

3. Refer the client to a religious counselor.

4. Explain to the client that God has his own reasons that most of us do not understand.

Correct Answer: 3

Rationale 1: Religious counselors often understand the emotional issues surrounding abuse and violence, and are sensitive to the needs of survivors to work slowly through their spiritual struggles. Encouraging the client to attend religious activities does not address the issues of trust, rage, and grief, and minimizes their severity. Although a survivor support group can be helpful, the client at this phase requires specific, consistent, and ongoing professional assistance to work through those intense feelings. Stating that God has his own reasons is a personal opinion and has no therapeutic value.

Rationale 2: Religious counselors often understand the emotional issues surrounding abuse and violence, and are sensitive to the needs of survivors to work slowly through their spiritual struggles. Encouraging the client to attend religious activities does not address the issues of trust, rage, and grief, and minimizes their severity. Although a survivor support group can be helpful, the client at this phase requires specific, consistent, and ongoing professional assistance to work through those intense feelings. Stating that God has his own reasons is a personal opinion and has no therapeutic value.

Rationale 3: Religious counselors often understand the emotional issues surrounding abuse and violence, and are sensitive to the needs of survivors to work slowly through their spiritual struggles. Encouraging the client to attend religious activities does not address the issues of trust, rage, and grief, and minimizes their severity. Although a survivor support group can be helpful, the client at this phase requires specific, consistent, and ongoing professional assistance to work through those intense feelings. Stating that God has his own reasons is a personal opinion and has no therapeutic value.

Rationale 4: Religious counselors often understand the emotional issues surrounding abuse and violence, and are sensitive to the needs of survivors to work slowly through their spiritual struggles. Encouraging the client to attend religious activities does not address the issues of trust, rage, and grief, and minimizes their severity. Although a survivor support group can be helpful, the client at this phase requires specific, consistent, and ongoing professional assistance to work through those intense feelings. Stating that God has his own reasons is a personal opinion and has no therapeutic value.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain why spiritual recovery is important for persons who have been victims of violence.

Question 21

Type: MCSA

A victim of sexual abuse expresses the belief to the nurse that the abuse is a punishment for not having lived a spiritually pure life prior to the event. The nurse:

1. Indicates to the victim that this is an incorrect view.

2. Makes it clear to the client that the rape was not a punishment for the clients own behavior.

3. Acknowledges the clients spiritual frustration and invites the client to express these feelings.

4. Explains that rape can happen even to the most religious people.

Correct Answer: 3

Rationale 1: The nurse validates the clients spiritual struggle and at the same time invites the client to express these feelings. This allows the client to grieve and ultimately to heal. The other responses are nontherapeutic, offer judgment, minimize the clients spiritual struggle, and/or may inhibit the clients willingness to work through feelings of guilt and responsibility for the attack.

Rationale 2: The nurse validates the clients spiritual struggle and at the same time invites the client to express these feelings. This allows the client to grieve and ultimately to heal. The other responses are nontherapeutic, offer judgment, minimize the clients spiritual struggle, and/or may inhibit the clients willingness to work through feelings of guilt and responsibility for the attack.

Rationale 3: The nurse validates the clients spiritual struggle and at the same time invites the client to express these feelings. This allows the client to grieve and ultimately to heal. The other responses are nontherapeutic, offer judgment, minimize the clients spiritual struggle, and/or may inhibit the clients willingness to work through feelings of guilt and responsibility for the attack.

Rationale 4: The nurse validates the clients spiritual struggle and at the same time invites the client to express these feelings. This allows the client to grieve and ultimately to heal. The other responses are nontherapeutic, offer judgment, minimize the clients spiritual struggle, and/or may inhibit the clients willingness to work through feelings of guilt and responsibility for the attack.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain why spiritual recovery is important for persons who have been victims of violence.

Question 22

Type: MCSA

An abused client in the inpatient unit recovering from injuries asks to attend Mass at the hospital chapel. The nurse understands that it is important for the client to:

1. Attend to spiritual needs in order to deal with what has happened.

2. Get back to a normal routine as soon as possible.

3. Find a distraction from the injuries.

4. Show an interest in what is going on in the world.

Correct Answer: 1

Rationale 1: The nurse understands the importance of spiritual support in the recovery process. The client may be struggling with questions or experiencing feelings of rage and grief. This is an important component of the process that will help the client move to a phase of self-forgiveness and healing. The client may wish to attend Mass for the other reasons given, but the nurse knows that these are not as significant to the recovery process.

Rationale 2: The nurse understands the importance of spiritual support in the recovery process. The client may be struggling with questions or experiencing feelings of rage and grief. This is an important component of the process that will help the client move to a phase of self-forgiveness and healing. The client may wish to attend Mass for the other reasons given, but the nurse knows that these are not as significant to the recovery process.

Rationale 3: The nurse understands the importance of spiritual support in the recovery process. The client may be struggling with questions or experiencing feelings of rage and grief. This is an important component of the process that will help the client move to a phase of self-forgiveness and healing. The client may wish to attend Mass for the other reasons given, but the nurse knows that these are not as significant to the recovery process.

Rationale 4: The nurse understands the importance of spiritual support in the recovery process. The client may be struggling with questions or experiencing feelings of rage and grief. This is an important component of the process that will help the client move to a phase of self-forgiveness and healing. The client may wish to attend Mass for the other reasons given, but the nurse knows that these are not as significant to the recovery process.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain why spiritual recovery is important for persons who have been victims of violence.

Question 23

Type: MCSA

A community health-planning group is meeting to discuss increasing violence among children in the community. Which setting would be expected to have the lowest occurrence of violence?

1. Schools

2. Streets

3. Residential centers

4. Homes

Correct Answer: 1

Rationale 1: Schools are controlled, structured environments intended to foster individuality, respect, and learning. Research supports that as many as 80% of male abusers come from homes in which they were abused or observed their mothers being abused. The home setting, therefore, has a higher occurrence of violence, followed by streets and residential centers, which also have higher occurrences of violence than schools.

Rationale 2: Schools are controlled, structured environments intended to foster individuality, respect, and learning. Research supports that as many as 80% of male abusers come from homes in which they were abused or observed their mothers being abused. The home setting, therefore, has a higher occurrence of violence, followed by streets and residential centers, which also have higher occurrences of violence than schools.

Rationale 3: Schools are controlled, structured environments intended to foster individuality, respect, and learning. Research supports that as many as 80% of male abusers come from homes in which they were abused or observed their mothers being abused. The home setting, therefore, has a higher occurrence of violence, followed by streets and residential centers, which also have higher occurrences of violence than schools.

Rationale 4: Schools are controlled, structured environments intended to foster individuality, respect, and learning. Research supports that as many as 80% of male abusers come from homes in which they were abused or observed their mothers being abused. The home setting, therefore, has a higher occurrence of violence, followed by streets and residential centers, which also have higher occurrences of violence than schools.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Incorporate into your nursing role the specific advocacy actions you would take to reduce family violence.

Question 24

Type: MCSA

When working with a client who has exhibited a pattern of violent outbursts followed by remorse, a nurses plan of care should focus on:

1. Decreasing the clients stressors.

2. Developing effective anger management techniques.

3. Offering the client family counseling.

4. Identifying the clients strengths.

Correct Answer: 2

Rationale 1: Among these answer choices, only anger management techniques may assist the client to develop healthier ways to deal with frustration that leads to violent outbursts. The other options may improve the clients and familys wellbeing, but do not address the abusive behaviors.

Rationale 2: Among these answer choices, only anger management techniques may assist the client to develop healthier ways to deal with frustration that leads to violent outbursts. The other options may improve the clients and familys wellbeing, but do not address the abusive behaviors.

Rationale 3: Among these answer choices, only anger management techniques may assist the client to develop healthier ways to deal with frustration that leads to violent outbursts. The other options may improve the clients and familys wellbeing, but do not address the abusive behaviors.

Rationale 4: Among these answer choices, only anger management techniques may assist the client to develop healthier ways to deal with frustration that leads to violent outbursts. The other options may improve the clients and familys wellbeing, but do not address the abusive behaviors.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate into your nursing role the specific advocacy actions you would take to reduce family violence.

Question 25

Type: MCSA

Which of the following statements made by an abusive family member in a counseling session indicates that the individual has learned positive coping skills?

1. I feel more prepared to care for my father now that I know where to go for assistance.

2. I am so sorry I lost control; it will never happen again.

3. From now on I will make sure that my fathers needs are met.

4. Now that I realize I treated my father unfairly, I will change my ways.

Correct Answer: 1

Rationale 1: Caring for an older adult at home can cause the family to become frustrated, overextended, and financially depleted. Knowing where to go in the community for assistance with caregiving can bring significant relief and, as a result, reduce violence. Outlining a specific plan for how to handle stressful caregiving shows that the caregiver has developed some effective coping skills. Realizing the unfairness of the treatment does not guarantee that the individual has a realistic, appropriate, and specific plan in place on how to cope with the stressors of caregiving. Saying that the abuse will never happen again does not indicate that the person has a specific plan in place to ensure that it does not happen again. Similarly, making sure that all of the fathers needs are met is vague and unrealistic and does not present positive coping skills that the person has to deal with the demands of care.

Rationale 2: Caring for an older adult at home can cause the family to become frustrated, overextended, and financially depleted. Knowing where to go in the community for assistance with caregiving can bring significant relief and, as a result, reduce violence. Outlining a specific plan for how to handle stressful caregiving shows that the caregiver has developed some effective coping skills. Realizing the unfairness of the treatment does not guarantee that the individual has a realistic, appropriate, and specific plan in place on how to cope with the stressors of caregiving. Saying that the abuse will never happen again does not indicate that the person has a specific plan in place to ensure that it does not happen again. Similarly, making sure that all of the fathers needs are met is vague and unrealistic and does not present positive coping skills that the person has to deal with the demands of care.

Rationale 3: Caring for an older adult at home can cause the family to become frustrated, overextended, and financially depleted. Knowing where to go in the community for assistance with caregiving can bring significant relief and, as a result, reduce violence. Outlining a specific plan for how to handle stressful caregiving shows that the caregiver has developed some effective coping skills. Realizing the unfairness of the treatment does not guarantee that the individual has a realistic, appropriate, and specific plan in place on how to cope with the stressors of caregiving. Saying that the abuse will never happen again does not indicate that the person has a specific plan in place to ensure that it does not happen again. Similarly, making sure that all of the fathers needs are met is vague and unrealistic and does not present positive coping skills that the person has to deal with the demands of care.

Rationale 4: Caring for an older adult at home can cause the family to become frustrated, overextended, and financially depleted. Knowing where to go in the community for assistance with caregiving can bring significant relief and, as a result, reduce violence. Outlining a specific plan for how to handle stressful caregiving shows that the caregiver has developed some effective coping skills. Realizing the unfairness of the treatment does not guarantee that the individual has a realistic, appropriate, and specific plan in place on how to cope with the stressors of caregiving. Saying that the abuse will never happen again does not indicate that the person has a specific plan in place to ensure that it does not happen again. Similarly, making sure that all of the fathers needs are met is vague and unrealistic and does not present positive coping skills that the person has to deal with the demands of care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate into your nursing role the specific advocacy actions you would take to reduce family violence.

Question 26

Type: MCSA

As a nurse advocate for the reduction of family elder abuse, a nurse:

1. Locates community resources for families.

2. Educates the public about legal consequences of violent acts.

3. Helps abused victims make it to the hospital for treatment.

4. Encourages abusers to come forward to talk about their issues.

Correct Answer: 1

Rationale 1: Caring for an older adult at home can be difficult and time consuming as well as physically, emotionally, and financially burdensome. Ongoing, accumulated stress can lead to violence. Knowing where to go in the community for assistance with caring can bring significant relief and, as a result, reduce violence. Focusing on legal consequences and asking abusers to come forward may place families on the defensive. Victims may not be in a position physically or cognitively to report to their abuse to the nurse. The goal in this case is family violence prevention rather than seeking treatment.

Rationale 2: Caring for an older adult at home can be difficult and time consuming as well as physically, emotionally, and financially burdensome. Ongoing, accumulated stress can lead to violence. Knowing where to go in the community for assistance with caring can bring significant relief and, as a result, reduce violence. Focusing on legal consequences and asking abusers to come forward may place families on the defensive. Victims may not be in a position physically or cognitively to report to their abuse to the nurse. The goal in this case is family violence prevention rather than seeking treatment.

Rationale 3: Caring for an older adult at home can be difficult and time consuming as well as physically, emotionally, and financially burdensome. Ongoing, accumulated stress can lead to violence. Knowing where to go in the community for assistance with caring can bring significant relief and, as a result, reduce violence. Focusing on legal consequences and asking abusers to come forward may place families on the defensive. Victims may not be in a position physically or cognitively to report to their abuse to the nurse. The goal in this case is family violence prevention rather than seeking treatment.

Rationale 4: Caring for an older adult at home can be difficult and time consuming as well as physically, emotionally, and financially burdensome. Ongoing, accumulated stress can lead to violence. Knowing where to go in the community for assistance with caring can bring significant relief and, as a result, reduce violence. Focusing on legal consequences and asking abusers to come forward may place families on the defensive. Victims may not be in a position physically or cognitively to report to their abuse to the nurse. The goal in this case is family violence prevention rather than seeking treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate into your nursing role the specific advocacy actions you would take to reduce family violence.

Question 27

Type: MCSA

A new nurse feels that it is hopeless to provide sexual and physical abuse victims with community resources when most of them choose to go back and live with their abusers. What would be an appropriate response by the counselor?

1. Some of these clients dont know any better.

2. We are mandated by law to give clients information on resources prior to discharge.

3. It is important to empower clients and help them see that they can make positive changes.

4. Sometimes things do improve at home.

Correct Answer: 3

Rationale 1: Empowering the victim is an important step in the recovery process. The victim knows that what is happening is wrong and that there may be setbacks, but the nurses role is to help set the stage for movement towards an abuse-free future. Every client should have a discharge plan prior to leaving the hospital, but this practice is not mandated by law. Things rarely improve in abusive homes without outside intervention.

Rationale 2: Empowering the victim is an important step in the recovery process. The victim knows that what is happening is wrong and that there may be setbacks, but the nurses role is to help set the stage for movement towards an abuse-free future. Every client should have a discharge plan prior to leaving the hospital, but this practice is not mandated by law. Things rarely improve in abusive homes without outside intervention.

Rationale 3: Empowering the victim is an important step in the recovery process. The victim knows that what is happening is wrong and that there may be setbacks, but the nurses role is to help set the stage for movement towards an abuse-free future. Every client should have a discharge plan prior to leaving the hospital, but this practice is not mandated by law. Things rarely improve in abusive homes without outside intervention.

Rationale 4: Empowering the victim is an important step in the recovery process. The victim knows that what is happening is wrong and that there may be setbacks, but the nurses role is to help set the stage for movement towards an abuse-free future. Every client should have a discharge plan prior to leaving the hospital, but this practice is not mandated by law. Things rarely improve in abusive homes without outside intervention.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Formulate a plan for managing personal feelings and attitudes that may affect professional practice when caring for victims of violence.

Question 28

Type: MCSA

Which statement by a nurse would indicate a nonjudgmental attitude toward violence and abuse?

1. Parents should not allow their children to party in the middle of the night; this is when most date rapes happen.

2. I admitted an 18-year-old for a suicide attempt following a date rape.

3. Most people who have sex when drunk tend to perceive it as rape.

4. Most adolescents call it rape when they dont enjoy a sexual experience.

Correct Answer: 2

Rationale 1: The statement, I admitted an 18-year-old for a suicide attempt following a date rape is objective and nonjudgmental. The other statements express personal bias or assume victims are to blame or complicit in their own rapes. These are subjective judgments and are not therapeutic.

Rationale 2: The statement, I admitted an 18-year-old for a suicide attempt following a date rape is objective and nonjudgmental. The other statements express personal bias or assume victims are to blame or complicit in their own rapes. These are subjective judgments and are not therapeutic.

Rationale 3: The statement, I admitted an 18-year-old for a suicide attempt following a date rape is objective and nonjudgmental. The other statements express personal bias or assume victims are to blame or complicit in their own rapes. These are subjective judgments and are not therapeutic.

Rationale 4: The statement, I admitted an 18-year-old for a suicide attempt following a date rape is objective and nonjudgmental. The other statements express personal bias or assume victims are to blame or complicit in their own rapes. These are subjective judgments and are not therapeutic.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate a plan for managing personal feelings and attitudes that may affect professional practice when caring for victims of violence.

Question 29

Type: MCSA

Nurses working with abused clients most commonly feel:

1. Sadness for the victim, tolerance toward the abuser.

2. Sympathy for the victim, indifference toward the abuser.

3. Anger toward the victim, dislike for the abuser.

4. Sympathy for the victim, anger toward the abuser.

Correct Answer: 4

Rationale 1: The most commonly experienced emotions of a nurse working with a victim of abuse include intense protective feelings and sympathy for the victim, and anger toward the abuser.

Rationale 2: The most commonly experienced emotions of a nurse working with a victim of abuse include intense protective feelings and sympathy for the victim, and anger toward the abuser.

Rationale 3: The most commonly experienced emotions of a nurse working with a victim of abuse include intense protective feelings and sympathy for the victim, and anger toward the abuser.

Rationale 4: The most commonly experienced emotions of a nurse working with a victim of abuse include intense protective feelings and sympathy for the victim, and anger toward the abuser.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Formulate a plan for managing personal feelings and attitudes that may affect professional practice when caring for victims of violence.

Question 30

Type: MCSA

In caring for victims of violence it is important for nurses to be aware of their personal feelings and attitudes about the situation because:

1. Intense negative feelings interfere with assessment and judgment.

2. It allows the nurse to express sympathy for the client.

3. Intense protective feelings result in appropriate interventions for the victims care.

4. Self-awareness protects the nurses own mental health.

Correct Answer: 1

Rationale 1: Dealing with intense personal feelings will affect objectivity, and the focus of interventions will shift from the victim to the nurse. Intense protective feelings may lead to over-involvement, which can negatively affect thorough assessment of the situation and implementation of appropriate care for the victim. Nurses should express empathy toward clients rather than sympathy. While the nurses mental health is important, it is secondary to unbiased assessment and judgment.

Rationale 2: Dealing with intense personal feelings will affect objectivity, and the focus of interventions will shift from the victim to the nurse. Intense protective feelings may lead to over-involvement, which can negatively affect thorough assessment of the situation and implementation of appropriate care for the victim. Nurses should express empathy toward clients rather than sympathy. While the nurses mental health is important, it is secondary to unbiased assessment and judgment.

Rationale 3: Dealing with intense personal feelings will affect objectivity, and the focus of interventions will shift from the victim to the nurse. Intense protective feelings may lead to over-involvement, which can negatively affect thorough assessment of the situation and implementation of appropriate care for the victim. Nurses should express empathy toward clients rather than sympathy. While the nurses mental health is important, it is secondary to unbiased assessment and judgment.

Rationale 4: Dealing with intense personal feelings will affect objectivity, and the focus of interventions will shift from the victim to the nurse. Intense protective feelings may lead to over-involvement, which can negatively affect thorough assessment of the situation and implementation of appropriate care for the victim. Nurses should express empathy toward clients rather than sympathy. While the nurses mental health is important, it is secondary to unbiased assessment and judgment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Formulate a plan for managing personal feelings and attitudes that may affect professional practice when caring for victims of violence.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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