Nokea
An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment?
- A. Interpersonal relationships
- B. Work responsibilities
- C. Socialization skills
- D. Physical injuries
Correct Answer: D
Rationale: The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.
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A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, 'My father doesn't like me. He calls me stupid all the time.' The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? (Select all that apply.)
- A. Parental sessions to teach child-rearing practices
- B. Anger management counseling for the father
- C. Continuing home visits to provide support
- D. Safety plan for the wife and children
- E. Foster placement of the children in foster care
Correct Answer: A,B,C
Rationale: Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.
After treatment for a detached retina, a victim of intimate partner violence says, 'My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me.' Which nursing diagnosis applies?
- A. Social isolation, related to lack of community support system
- B. Risk for injury, related to partner's physical abuse when intoxicated
- C. Deficient knowledge, related to resources for escape from the abusive relationship
- D. Disabled family coping, related to uneven distribution of power within a relationship
Correct Answer: B
Rationale: Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.
An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the employee says, 'My partner beat me, but it was because there are problems at work.' What should the nurse's next action be?
- A. Notify the police.
- B. Refer the employee to a shelter.
- C. Notify the adult protective agency.
- D. Document injuries with a body map.
Correct Answer: D
Rationale: Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. A shelter may be suggested later, but it is not the next action.
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.
Which family scenario presents the greatest risk for family violence?
- A. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
- B. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder
- C. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care
- D. A single homosexual male parent and an adolescent son who has just begun dating girls
Correct Answer: A
Rationale: The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.