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A clinic nurse interviews an adult patient accompanied by a partner who reports fatigue, back pain, headaches, tension, and sleep disturbances. The patient then becomes reluctant to provide more information and wants to leave. How can the nurse best serve the patient?
- A. Explore the possibility of patient social isolation.
- B. Have the partner leave the patient alone to continue the assessment.
- C. Ask whether the patient has ever had psychiatric counseling in the past.
- D. Ask the patient to disrobe so that assessment for signs of physical abuse can occur.
Correct Answer: B
Rationale: 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, he or she may be willing to speak more candidly if the partner is not in the room. None of the other options focus on the client's reluctance to continue the assessment process.
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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 can't 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.
Correct Answer: B
Rationale: A 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.
A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, 'Why are you such a stupid kid?' The wife says, 'I have difficulty disciplining the children. It's so frustrating.' Which comments by the nurse will facilitate the interview with these parents? (Select all that apply.)
- A. Tell me how you punish your children.
- B. How do you stop your baby from crying?
- C. Caring for four small children must be difficult.
- D. Do you or your husband ever beat the children?
- E. Calling children 'stupid' injures their self-esteem.
Correct Answer: A,B,C
Rationale: An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by 'yes' or 'no.'
An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment question?
- A. Do you drink excessively?
- B. Did your partner beat you?
- C. How did this happen to you?
- D. What did you do to deserve this?
Correct Answer: C
Rationale: Obtaining the person's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.
A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? (Select all that apply.)
- A. Keep a cell phone fully charged.
- B. Hide money with which to buy new clothes.
- C. Have the telephone number for the nearest shelter.
- D. Take enough toys to amuse the children for 2 days.
- E. Secure a supply of current medications for self and children.
- F. Determine a code word to signal children that it is time to leave.
- G. Assemble birth certificates, Social Security cards, and licenses.
Correct Answer: A,C,E,F,G
Rationale: The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.
An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, 'My parents don't like me. They call me stupid and say I never do anything right.' Which type of abuse is likely?
- A. Sexual
- B. Physical
- C. Emotional
- D. Economic
Correct Answer: C
Rationale: Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.