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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.
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An older adult diagnosed with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse?
- A. Dementia
- B. Living in a rural area
- C. Being part of a busy family
- D. Being home only in the evening
Correct Answer: A
Rationale: Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?
- A. Self-awareness protects one's own mental health.
- B. Strong negative feelings interfere with assessment and judgment.
- C. Strong positive feelings lead to under involvement with the victim.
- D. Positive feelings promote the development of sympathy for patients.
Correct Answer: B
Rationale: Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.
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 11-year-old child says, 'My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn.' Which nursing diagnosis applies to this child?
- A. Chronic low self-esteem, related to negative feedback from parents
- B. Deficient knowledge, related to interpersonal skills with parents
- C. Disturbed personal identity, related to negative self-evaluation
- D. Complicated grieving, related to poor academic performance
Correct Answer: A
Rationale: The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.
An adult tells the nurse, 'My partner abuses me only when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it.' Which phase in the cycle of violence prevents the patient from leaving?
- A. Tension building
- B. Acute battering
- C. Honeymoon
- D. Recovery
Correct Answer: C
Rationale: The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.