Abuse, Neglect & Violence NCLEX: Study Guide 2025
A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing
response?
1. To decrease the victimizer's insecurity.
2. To inflict physical harm with the weapon.
3. To terrorize and subdue the victim.
4. To mirror learned family behavior patterns related to weapons. - ans3 ~ The nurse should explain that a
rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by
means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to
insistence on sexual intercourse by an acquaintance or spouse.
A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur
before bedtime. She has never married or dated, and she lives alone. She states to a nurse, My father has
recently moved back to town. What should the nurse suspect?
1. Possible major depressive disorder
2. Possible history of childhood incest
3. Possible histrionic personality disorder
4. Possible history of childhood physical abuse - ans2 ~ The nurse should suspect that this client may have a
history of childhood incest. Adult survivors of incest are at risk for developing post-traumatic stress disorder,
sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating
disorders, and substance abuse disorders.
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. - ans2 ~ 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 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.
3. These clients often have a lack of financial independence to support themselves and their children, and most
have religious beliefs prohibiting divorce and separation.
4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. -
ans4 ~ The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed
into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay
with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support
network, for religious reasons, or because of hopefulness.
A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances.
The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How
can the nurse best serve the patient?
a. Explore the possibility of patient social isolation.
b. Have the patient complete an abuse assessment screen.
c. Ask whether the patient has ever had psychiatric counseling.
d. Ask the patient to disrobe; then assess for signs of physical abuse. - ansB ~ In this situation, the nurse should
consider the possibility that the patient is a victim of intimate partner violence. Although the patient is
reluctant to discuss issues, she may be willing to fill out an abuse assessment screen, which would then open
the door to discussion.
A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy,
which client statement should indicate to a nurse that the student is handling this situation in a healthy
manner?
1. I know that it was not my fault.
2. My boyfriend has trouble controlling his sexual urges.
3. If I don't put myself in a dating situation, I won't be at risk.
4. Next time I will think twice about wearing a sexy dress. - ans1 ~ The client who realizes that sexual assault
was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental
listening and communicate statements that instill trust and validate self-worth.
A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing
response?
1. To decrease the victimizer's insecurity.
2. To inflict physical harm with the weapon.
3. To terrorize and subdue the victim.
4. To mirror learned family behavior patterns related to weapons. - ans3 ~ The nurse should explain that a
rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by
means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to
insistence on sexual intercourse by an acquaintance or spouse.
A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur
before bedtime. She has never married or dated, and she lives alone. She states to a nurse, My father has
recently moved back to town. What should the nurse suspect?
1. Possible major depressive disorder
2. Possible history of childhood incest
3. Possible histrionic personality disorder
4. Possible history of childhood physical abuse - ans2 ~ The nurse should suspect that this client may have a
history of childhood incest. Adult survivors of incest are at risk for developing post-traumatic stress disorder,
sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating
disorders, and substance abuse disorders.
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. - ans2 ~ 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 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.
3. These clients often have a lack of financial independence to support themselves and their children, and most
have religious beliefs prohibiting divorce and separation.
4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. -
ans4 ~ The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed
into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay
with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support
network, for religious reasons, or because of hopefulness.
A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances.
The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How
can the nurse best serve the patient?
a. Explore the possibility of patient social isolation.
b. Have the patient complete an abuse assessment screen.
c. Ask whether the patient has ever had psychiatric counseling.
d. Ask the patient to disrobe; then assess for signs of physical abuse. - ansB ~ In this situation, the nurse should
consider the possibility that the patient is a victim of intimate partner violence. Although the patient is
reluctant to discuss issues, she may be willing to fill out an abuse assessment screen, which would then open
the door to discussion.
A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy,
which client statement should indicate to a nurse that the student is handling this situation in a healthy
manner?
1. I know that it was not my fault.
2. My boyfriend has trouble controlling his sexual urges.
3. If I don't put myself in a dating situation, I won't be at risk.
4. Next time I will think twice about wearing a sexy dress. - ans1 ~ The client who realizes that sexual assault
was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental
listening and communicate statements that instill trust and validate self-worth.
