NCLEX Substance Abuse Nursing
Questions | Psychiatric Nursing
Challenge Exam 100% Accurate
1. 1. Question
Sheila tells the community nurse that her boyfriend has been abusive and she is
afraid of him, but she doesn’t want to leave. The client asks the nurse for
assistance. Which nursing interventions are appropriate in this situation? Select
all that apply.
A. Help Sheila to develop a plan to ensure safety, including phone numbers
for emergency help.
B. Help Sheila to get her boyfriend into an appropriate treatment program.
C. Communicate acceptance, avoiding any implication that Sheila is at fault
for not leaving.
D. Help Sheila to explore available options, including shelters and legal
protection.
E. Tell Sheila that she should leave because things will not improve.
F. Reinforce concern for Sheila's safety and her right to be free of abuse.
Correct Answer: A, C, D, F
These are all appropriate nursing interventions for the victim of domestic
violence. The client is not responsible for seeking help for the abuser, and
encouraging her to do so may reinforce the client’s feeling responsible for the
abuse. Advising the client must decide for herself whether to leave, and the nurse
must respect any decision the client makes. Making the decision for the client will
erode her self-esteem and reinforce her sense of powerlessness.
2. 2. Question
Which nursing assessment findings are physical signs of sexual abuse of a female
child? Select all that apply.
A. Enuresis
, B. Red and swollen labia and rectum
C. Vaginal tears
D. Injuries in different stages of healing
E. Cigarette burns
F. Lice infestation
Correct Answer: A, B, C
These are all indications that a female child has been the victim of sexual abuse.
Children often do not talk about sexual abuse because they think it is their fault
or they have been convinced by their abuser that it is normal or a “special secret”.
Options D, E, and F are signs of physical abuse of a child, not sexual abuse. In the
short term, children may suffer health issues, such as sexually transmitted
infections, physical injuries and unwanted pregnancies. In the long term, people
who have been sexually abused are more likely to suffer from depression, anxiety,
eating disorders and post-traumatic stress disorder (PTSD). They’re also more
likely to self-harm, become involved in criminal behavior, misuse drugs, and
alcohol, and to commit suicide as young adults.
3. 3. Question
During a prenatal assessment, the clinic nurse suspects that her client was
abused. Which of the following questions would be most appropriate?
A. "Are you being threatened or hurt by your partner?"
B. "Are you frightened of your partner?"
C. "Is something bothering you?"
D. "What happens when you and your partner argue?"
Correct Answer: A. “Are you being threatened or hurt by your partner?”
The use of simple, direct questions, asked in an emphatic manner, is best to
validate the presence of an abusive situation. The evaluation should start with a
detailed history and physical examination. Clinicians should screen all females for
domestic violence, and refer to females who screen positive. This includes
females who do not have signs or symptoms of abuse. All healthcare facilities
should have a plan in place that provides for assessing, screening, and referring
patients for intimate partner violence. Protocols should include referral,
documentation, and follow-up.
, 4. 4. Question
Which situation would Nurse Sally identify as placing a client at high risk for
caregiver abuse?
A. Antonia, an adult child, quits her job to move in and care for a parent with
severe dementia.
B. Mr. Wright, an elderly man with severe heart disease, resides in a personal
care home and is frequently visited by his adult child.
C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives
help from several adult children.
D. Antoinette cares for her husband who is in early stages of Alzheimer's
disease and has a network of available support persons.
Correct Answer: A. Antonia quits her job to move in and care for a parent
with severe dementia.
In this situation, the adult child has given up her usual role as well as moved her
place of residence to care for her parents. Caring for someone with severe
dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and
meet needs. This situation places the caregiver at high risk for stress and abuse. A
combination of individual, relational, community, and societal factors contribute
to the risk of becoming a perpetrator of elder abuse. They are contributing
factors and may or may not be direct causes.
5. 5. Question
The interventions common to treatment plans for survivors include which of the
following? Select all that apply.
A. Establish trust and rapport.
B. Identify areas of control.
C. Remove the client from home.
D. Support the client in the decisions he/she makes.
E. Encourage the client to pursue legal action.
Correct Answers: A, B, & D
Identifying areas of control empowers the client. Supporting the client in the
decisions he/she makes empowers the client and enhances the client’s current
Questions | Psychiatric Nursing
Challenge Exam 100% Accurate
1. 1. Question
Sheila tells the community nurse that her boyfriend has been abusive and she is
afraid of him, but she doesn’t want to leave. The client asks the nurse for
assistance. Which nursing interventions are appropriate in this situation? Select
all that apply.
A. Help Sheila to develop a plan to ensure safety, including phone numbers
for emergency help.
B. Help Sheila to get her boyfriend into an appropriate treatment program.
C. Communicate acceptance, avoiding any implication that Sheila is at fault
for not leaving.
D. Help Sheila to explore available options, including shelters and legal
protection.
E. Tell Sheila that she should leave because things will not improve.
F. Reinforce concern for Sheila's safety and her right to be free of abuse.
Correct Answer: A, C, D, F
These are all appropriate nursing interventions for the victim of domestic
violence. The client is not responsible for seeking help for the abuser, and
encouraging her to do so may reinforce the client’s feeling responsible for the
abuse. Advising the client must decide for herself whether to leave, and the nurse
must respect any decision the client makes. Making the decision for the client will
erode her self-esteem and reinforce her sense of powerlessness.
2. 2. Question
Which nursing assessment findings are physical signs of sexual abuse of a female
child? Select all that apply.
A. Enuresis
, B. Red and swollen labia and rectum
C. Vaginal tears
D. Injuries in different stages of healing
E. Cigarette burns
F. Lice infestation
Correct Answer: A, B, C
These are all indications that a female child has been the victim of sexual abuse.
Children often do not talk about sexual abuse because they think it is their fault
or they have been convinced by their abuser that it is normal or a “special secret”.
Options D, E, and F are signs of physical abuse of a child, not sexual abuse. In the
short term, children may suffer health issues, such as sexually transmitted
infections, physical injuries and unwanted pregnancies. In the long term, people
who have been sexually abused are more likely to suffer from depression, anxiety,
eating disorders and post-traumatic stress disorder (PTSD). They’re also more
likely to self-harm, become involved in criminal behavior, misuse drugs, and
alcohol, and to commit suicide as young adults.
3. 3. Question
During a prenatal assessment, the clinic nurse suspects that her client was
abused. Which of the following questions would be most appropriate?
A. "Are you being threatened or hurt by your partner?"
B. "Are you frightened of your partner?"
C. "Is something bothering you?"
D. "What happens when you and your partner argue?"
Correct Answer: A. “Are you being threatened or hurt by your partner?”
The use of simple, direct questions, asked in an emphatic manner, is best to
validate the presence of an abusive situation. The evaluation should start with a
detailed history and physical examination. Clinicians should screen all females for
domestic violence, and refer to females who screen positive. This includes
females who do not have signs or symptoms of abuse. All healthcare facilities
should have a plan in place that provides for assessing, screening, and referring
patients for intimate partner violence. Protocols should include referral,
documentation, and follow-up.
, 4. 4. Question
Which situation would Nurse Sally identify as placing a client at high risk for
caregiver abuse?
A. Antonia, an adult child, quits her job to move in and care for a parent with
severe dementia.
B. Mr. Wright, an elderly man with severe heart disease, resides in a personal
care home and is frequently visited by his adult child.
C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives
help from several adult children.
D. Antoinette cares for her husband who is in early stages of Alzheimer's
disease and has a network of available support persons.
Correct Answer: A. Antonia quits her job to move in and care for a parent
with severe dementia.
In this situation, the adult child has given up her usual role as well as moved her
place of residence to care for her parents. Caring for someone with severe
dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and
meet needs. This situation places the caregiver at high risk for stress and abuse. A
combination of individual, relational, community, and societal factors contribute
to the risk of becoming a perpetrator of elder abuse. They are contributing
factors and may or may not be direct causes.
5. 5. Question
The interventions common to treatment plans for survivors include which of the
following? Select all that apply.
A. Establish trust and rapport.
B. Identify areas of control.
C. Remove the client from home.
D. Support the client in the decisions he/she makes.
E. Encourage the client to pursue legal action.
Correct Answers: A, B, & D
Identifying areas of control empowers the client. Supporting the client in the
decisions he/she makes empowers the client and enhances the client’s current
