Chapter 33: Survivors of Violence and Trauma
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. For a victim ofspousal abuse, a deterrent to leaving the abusive situation are the events that
occur in which stage?
a. Tension building
b. Honeymoon
c. Processing
d. Battering
ANS: B
In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of
the battering incident. The perpetrator promises never to repeat the battering. The events
occurring in the other options would not be deterrents to leaving. The processing stage is not an
actual stage in the cycle.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Psychosocial Integrity
2. A woman who has been repeatedly abused by her partner comes to the emergencydepartment
with severe contusions. She tells the nurse, ―I was almost killed this time. I need to do
something.‖ What is the nurse‘s priority intervention?
a. Document the woman‘s injuries.
b. Help the patient devise a safety or escape plan.
c. Encourage the patient to take independent action.
d. Provide referrals contingent on the patient leaving the abuser.
ANS: B
, Individuals who are victims of partner abuse should have an escape plan. This is of high priority
when the victim‘s life is endangered. Encouraging the victim to take independent action is of less
help than offering concrete assistance such as providing referrals and giving emergency phone
numbers. Referrals should never be contingent on leaving, which might be possible only after the
victim has made use of the referral and has assistance in place. Documentation is important, but
not the nurse‘s first action.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
3. Which intervention would be most therapeutic as a nurse provides initial care for a client who
was abused by their partner?
a. Validate the truthfulness of the victim‘s comments.
b. Avoid pressuring the victim or disparaging the abuser.
c. Acknowledge the victim‘s inability to change the situation.
d. Allow the partner to stay with the victim during an interview.
ANS: B
, Nurses should never pressure a victim to leave the abuser. The patient must make the decision
without coercion. Leaving is dangerous because it escalates the violence and might result in
death. Neither should the nurse disparage the perpetrator. The victim still cares about the
batterer. The nurse should ask directly about abuse. The nurse should not suggest that the
individual is unable to take constructive action. The patient should have a safe environment,
without the abuser, to discuss the events. The nurse should not question the truthfulness of the
victim‘s complaints.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The patient
has a history of binge/purge eating disorder as well as difficulty trusting and relating to others.
What is the nurse‘s priority intervention?
a. Set limits on self-harmful behavior.
b. Foster belief in and valuing of family unity.
c. Confront abnormal eating patterns and self-mutilation.
d. Encourage discussion of personal responsibilities associated with abuse.
ANS: A
Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs
of the patient. Individuation should be fostered. The victim should not be encouraged to accept
any personal responsibility for the abuse. The patient is aware of the eating patterns
and self-mutilation; confrontation will not build trust.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A woman accompanied by her domestic partner is being assessed for reports of neck pain.
When the nurse notes a bald spot on the client‘s scalp, the woman explains that she caught her
hair in a door, which pulled it out and caused her neck injury. What is the nurse‘s best action
to facilitate the assessment?
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. For a victim ofspousal abuse, a deterrent to leaving the abusive situation are the events that
occur in which stage?
a. Tension building
b. Honeymoon
c. Processing
d. Battering
ANS: B
In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of
the battering incident. The perpetrator promises never to repeat the battering. The events
occurring in the other options would not be deterrents to leaving. The processing stage is not an
actual stage in the cycle.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Psychosocial Integrity
2. A woman who has been repeatedly abused by her partner comes to the emergencydepartment
with severe contusions. She tells the nurse, ―I was almost killed this time. I need to do
something.‖ What is the nurse‘s priority intervention?
a. Document the woman‘s injuries.
b. Help the patient devise a safety or escape plan.
c. Encourage the patient to take independent action.
d. Provide referrals contingent on the patient leaving the abuser.
ANS: B
, Individuals who are victims of partner abuse should have an escape plan. This is of high priority
when the victim‘s life is endangered. Encouraging the victim to take independent action is of less
help than offering concrete assistance such as providing referrals and giving emergency phone
numbers. Referrals should never be contingent on leaving, which might be possible only after the
victim has made use of the referral and has assistance in place. Documentation is important, but
not the nurse‘s first action.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
3. Which intervention would be most therapeutic as a nurse provides initial care for a client who
was abused by their partner?
a. Validate the truthfulness of the victim‘s comments.
b. Avoid pressuring the victim or disparaging the abuser.
c. Acknowledge the victim‘s inability to change the situation.
d. Allow the partner to stay with the victim during an interview.
ANS: B
, Nurses should never pressure a victim to leave the abuser. The patient must make the decision
without coercion. Leaving is dangerous because it escalates the violence and might result in
death. Neither should the nurse disparage the perpetrator. The victim still cares about the
batterer. The nurse should ask directly about abuse. The nurse should not suggest that the
individual is unable to take constructive action. The patient should have a safe environment,
without the abuser, to discuss the events. The nurse should not question the truthfulness of the
victim‘s complaints.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The patient
has a history of binge/purge eating disorder as well as difficulty trusting and relating to others.
What is the nurse‘s priority intervention?
a. Set limits on self-harmful behavior.
b. Foster belief in and valuing of family unity.
c. Confront abnormal eating patterns and self-mutilation.
d. Encourage discussion of personal responsibilities associated with abuse.
ANS: A
Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs
of the patient. Individuation should be fostered. The victim should not be encouraged to accept
any personal responsibility for the abuse. The patient is aware of the eating patterns
and self-mutilation; confrontation will not build trust.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A woman accompanied by her domestic partner is being assessed for reports of neck pain.
When the nurse notes a bald spot on the client‘s scalp, the woman explains that she caught her
hair in a door, which pulled it out and caused her neck injury. What is the nurse‘s best action
to facilitate the assessment?
