Nokea
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.
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A nurse is working with a client who is a survivor of violence on developing a safety plan. Which of the following would the nurse address first?
- A. Devising an escape route
- B. Recognizing the signs of danger
- C. Identifying a safe place to hide
- D. Identifying a signal to indicate it is safe to leave
Correct Answer: B
Rationale: Recognizing the signs of danger (B) is the first step in a safety plan, as it enables the survivor to identify escalating risks and act proactively. Devising an escape route (A), finding a safe place to hide (C), or identifying a signal (D) are subsequent steps that rely on first recognizing danger.
The nurse is caring for a young adult in the mental health clinic. The client tells the nurse that he was physically neglected as a child. The nurse should assess the client for symptoms of which of the following?
- A. Major depression
- B. Schizophrenia
- C. Narcissistic personality disorder
- D. Panic disorder
Correct Answer: A
Rationale: Physical neglect in childhood is strongly associated with major depression (A) due to its impact on emotional development and self-esteem. Schizophrenia (B) has a stronger genetic basis, narcissistic personality disorder (C) is less directly linked to neglect, and panic disorder (D) is less commonly a primary outcome of neglect.
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 nurse is working with a female client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which of the following would be most important for the nurse to do?
- A. Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence.
- B. Inform the client that if she leaves the abusive situation, there is a possibility her partner will attempt to murder her.
- C. Assist the client in finding a new apartment and a new job so she will be safe after she leaves her current situation.
- D. Suggest that the client legally change her name and move out of state so she will be safe from future harm.
Correct Answer: C
Rationale: Assisting the client in finding a new apartment and job (C) provides practical support to ensure safety and independence, critical for leaving an abusive relationship. Describing the cycle of violence (A) is educational but less immediate, warning of murder (B) may heighten fear, and changing identity (D) is extreme and less feasible.
The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family?
- A. A top nursing priority will be to legally remove the son from the home.
- B. The main focus of the nurse?s actions should be on improving the elderly mother?s self-esteem.
- C. The nurse must allow the elderly mother to decide if she wants to leave the situation or not.
- D. Placement for the elderly woman in a nursing home within the community is crucial.
Correct Answer: C
Rationale: Allowing the elderly mother to decide whether to leave (C) respects her autonomy and is critical in abuse cases, ensuring empowerment and safety planning. Legal removal (A) is premature, self-esteem (B) is secondary, and nursing home placement (D) assumes a specific outcome without client input.