Nokea
A female client has been admitted to the inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority?
- A. Nutritional status
- B. Hydration status
- C. Sleep patterns
- D. Suicide risk
Correct Answer: D
Rationale: Suicide risk (D) is the priority in a client with PTSD due to intimate partner violence, as the trauma and emotional distress significantly increase suicidality. Nutritional status (A), hydration (B), and sleep patterns (C) are important but secondary to ensuring safety.
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The school nurse is aware that a student has requested aspirin three times during the past week because his back hurts. The nurse has noticed that he often wears long-sleeved sweaters and sweatshirts even in warm weather. The nurse suspects that the student may be the victim of physical abuse. The nurse is preparing to ask the child about his ongoing backache. Which of the following would the nurse anticipate being reported by the child if he was being abused?
- A. Explain that his father is beating him on a regular basis.
- B. Give a far-fetched explanation not logically connected to his injuries.
- C. Give the same reason his sister would give were she asked to explain his injuries.
- D. Carefully explain that his mother disciplines him because she loves him.
Correct Answer: B
Rationale: Children experiencing abuse often provide far-fetched or illogical explanations (B) to conceal the abuse due to fear or shame. Direct admission (A) is unlikely, matching a sibling?s story (C) is not typical, and justifying discipline as love (D) is less common in children.
A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following?
- A. Violence
- B. Intimidation
- C. Jealousy
- D. Fear
Correct Answer: B
Rationale: Stalking is a crime of intimidation (B), involving behaviors intended to control or frighten the victim. It is not always violent (A), jealousy (C) is a motive not a crime, and fear (D) is an outcome, not the defining characteristic.
A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment?
- A. Danger Assessment Screen
- B. Abuse Assessment Screen
- C. Burgess-Partner Abuse Scale
- D. Beck Depression Inventory
Correct Answer: A
Rationale: The Danger Assessment Screen (A) is specifically designed to assess the risk of lethal violence in abuse survivors, focusing on factors like threats or weapon use. The Abuse Assessment Screen (B) identifies abuse but not lethality, the Burgess scale (C) is less specific, and the Beck Depression Inventory (D) assesses depression, not lethality.
A nurse is preparing a presentation for an adolescent and young adult community group about stalking. Which group would the nurse identify as having the highest risk of being stalked?
- A. Boys and young men, ages 12 to 21 years
- B. Men, ages 24 to 28 years
- C. Girls and young women, ages 10 to 18 years
- D. Women, ages 18 to 24 years
Correct Answer: D
Rationale: Women ages 18 to 24 (D) have the highest risk of being stalked, particularly due to their vulnerability in dating and social contexts. Other groups (A, B, C) face lower risks, with women in this age range consistently showing higher prevalence in stalking statistics.
A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor?s partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?
- A. He always tells me that the abuse never happened.
- B. He tells me who I can and cannot see.
- C. He tells me that he?ll tell child services I?m a bad mother.
- D. He acts like he?s the master of his castle and I?m his servant.
Correct Answer: C
Rationale: Threatening to report to child services (C) is a clear example of coercion and threats, a tactic of power and control in IPV. Denying abuse (A) is gaslighting, controlling social interactions (B) is isolation, and acting superior (D) is emotional abuse, but threats (C) are most indicative of coercion.