2023 with complete solution
A nurse visits the home of an 11-year-old child and finds the child caring for three
younger siblings. Both parents are at work. The child says, "I want to go to school, but
we cant afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary
assessment is evident?
a. Insufficient data are present to make an assessment.
b. Child and siblings are experiencing neglect.
c. Children are at high risk for sexual abuse.
d. Children are experiencing physical abuse.
B ~ The child is experiencing neglect when the parents take away the opportunity to
attend school. The other children may also be experiencing physical neglect, but more
data should be gathered before making the actual assessment. The information
presented does not indicate a high risk for sexual abuse, and no concrete evidence of
physical abuse is present.
Which behavior best demonstrates aggression?
a. Stomping away from the nurses station, going to another room, and grabbing a snack
from another patient.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a
pillow and sobbing.
c. Telling the primary nurse, I felt angry when you said I could not have a second
helping at lunch.
d. Telling the medication nurse, I am not going to take that or any other medication you
try to give me.
A ~ Aggression is harsh physical or verbal action that reflects rage, hostility, and the
potential for physical or verbal destructiveness. Aggressive behavior violates the rights
of others. The incorrect options do not feature violation of anothers rights.
A kindergarten student is frequently violent toward other children. A school nurse
notices bruises and burns on the child's face and arms. What other symptom should
indicate to the nurse that the child may have been physically abused?
1. The child shrinks at the approach of adults.
2. The child begs or steals food or money.
3. The child is frequently absent from school.
4. The child is delayed in physical and emotional development.
1 ~ The nurse should determine that a child who shrinks at the approach of adults in
addition to having bruises and burns may be a victim of abuse. Maltreatment is
considered, whether or not the adult intended to harm the child.
A woman presents with a history of physical and emotional abuse in her intimate
relationships. What should this information lead a nurse to suspect?
1. The woman may be exhibiting a controlled response pattern.
2. The woman may have a history of childhood neglect.
3. The woman may be exhibiting codependent characteristics.
4. The woman may be a victim of incest.
, 4 ~ The nurse should suspect that this client may be a victim of incest. Many women
who are battered have low self-esteem and have feelings of guilt, anger, fear, and
shame. Women in abusive relationships often grew up in an abusive home.
A nursing instructor is developing a lesson plan to teach about domestic violence.
Which information should be included?
1. Power and control are central to the dynamic of domestic violence.
2. Poor communication and social isolation are central to the dynamic of domestic
violence.
3. Erratic relationships and vulnerability are central to the dynamic of domestic violence.
4. Emotional injury and learned helplessness are central to the dynamic of domestic
violence.
1 ~ The nursing instructor should include the concept that power and control are central
to the dynamic of domestic violence. Battering is defined as a pattern of coercive control
founded on physical and/or sexual violence or threat of violence. The typical abuser is
very possessive and perceives the victim as a possession.
A client is brought to an emergency department after being violently raped. Which
nursing action is appropriate?
1. Discourage the client from discussing the rape, because this may lead to further
emotional trauma.
2. Remain nonjudgmental while actively listening to the client's description of the violent
rape event.
3. Meet the client's self-care needs by assisting with showering and perineal care.
4. Probe for further, detailed description of the rape event.
2 ~ The most appropriate nursing action is to remain nonjudgmental and actively listen
to the clients description of the event. It is important to also communicate to the victim
that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an
avenue for catharsis, which contributes to the healing process.
A raped client answers a nurses questions in a monotone voice with single words,
appears calm, and exhibits a blunt affect. How should the nurse interpret this clients
responses?
1. The client may be lying about the incident.
2. The client may be experiencing a silent rape reaction.
3. The client may be demonstrating a controlled response pattern.
4. The client may be having a compounded rape reaction.
3 ~ This client is most likely demonstrating a controlled response pattern. In the
controlled response pattern, the client's feelings are masked or hidden, and a calm,
composed, or subdued affect is seen. In the expressed response pattern, feelings of
fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness,
and tension.
A client who is in a severely abusive relationship is admitted to a psychiatric inpatient
unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?"
Which is the nursing supervisors most appropriate response?
1. These clients don't know life any other way, and change is not an option until they
have improved insight.
2. These clients have limited cognitive skills and few vocational abilities to be able to
make it on their own.