Nokea
A young woman telephones the emergency department and loudly tells the nurse, 'I've been raped! Please help me!' Which of the following is the priority for the nurse to determine?
- A. If the client was in a safe place, her condition, and if transportation is available
- B. If the client knew her assailant, knew her location, and had notified the police
- C. If the client has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility
- D. If the client had bathed, douched, or changed clothes
Correct Answer: A
Rationale: Ensuring the client's safety, assessing her condition, and confirming transportation are the immediate priorities to provide appropriate care.
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The school nurse is teaching a health class about recognizing the signs of abusive relationships. The nurse describes the cycle of violence. The nurse would document effective teaching if the students identify the cycle of violence to be which of the following patterns? Select the order in which the events occur.
- A. Tension building
- B. Honeymoon period
- C. Violent behavior
- D. Period of remorse
Correct Answer: A,C,D,B
Rationale: The cycle of violence follows the pattern of tension building, violent behavior, period of remorse, and then a honeymoon period, repeating thereafter.
A school nurse is educating a group of adolescent girls about rape and sexual assault. The nurse evaluates the students' understanding when they report which of the following as a high-risk factor regarding the incidence of rape?
- A. The highest incidence of rape occurs in adolescents and young adult women.
- B. Most rapes are committed by strangers.
- C. Most rapes are random acts of violence.
- D. A victim is at highest risk in unfamiliar neighborhoods.
Correct Answer: A
Rationale: The highest incidence of rape occurs in girls and women aged 16-24, often by acquaintances, not strangers, and in familiar settings.
Which of the following are common behavioral and emotional responses to abuse? Select all that apply.
- A. One third of abusive men are likely to have come from violent homes.
- B. Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships.
- C. Dependency on the abuser is a common trait found in victims of domestic violence.
- D. The victim caused the abuse.
- E. It is critical for the nurse to demonstrate acceptance after hearing about the abuse so that the victim may begin to gain self-acceptance.
Correct Answer: A,B,C,E
Rationale: Abusive men often come from violent homes, women from such backgrounds may accept violence, victims are often dependent, and nurse acceptance aids self-acceptance; victims do not cause abuse.
The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which of the following data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse?
- A. The parents appearing overprotective of the child
- B. Bruises over the child's bony prominences
- C. The injury occurring several days before the parents sought treatment
- D. Both parents reporting the exact same details pertaining to the injurious event
Correct Answer: C
Rationale: A delay in seeking treatment for a significant injury like a fractured femur is a warning sign of potential physical abuse.
Which of the following are typical characteristics of the perpetrator of intimate partner abuse? Select all that apply.
- A. The perpetrator often believes that the partner is his own property.
- B. The perpetrator is often irrationally jealous, even of his own children.
- C. The perpetrator is emotionally immature and needy.
- D. The perpetrator respects his partner.
- E. The perpetrator is intimidated by his partner.
Correct Answer: A,B,C
Rationale: Perpetrators often view partners as property, exhibit irrational jealousy, and are emotionally immature and needy, but they do not respect or feel intimidated by their partner.