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The nurse is assessing an elderly female in the emergency department. There are many bruises present on her body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next?
- A. Ask the client when and how the bruises occurred
- B. Call the nursing supervisor immediately
- C. Follow the facility's policy and procedures for reporting abuse
- D. Notify the physician that abuse is suspected
Correct Answer: A
Rationale: Asking the client about the bruises is the next step to assess potential abuse before reporting or involving others.
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A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a woman would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which of the following approaches?
- A. Keeping focused on the client's feelings about her life situation
- B. Honestly asking the client why she repeats the cycles of victimization
- C. Convincing the client to develop a self-rescue plan
- D. Not prying into the details of the client's private life
Correct Answer: A
Rationale: Focusing on the client's feelings fosters a therapeutic relationship by validating her experiences without judgment or assumptions.
The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply.
- A. The client has few friends.
- B. The client holds a dominant role in the family.
- C. The client is in charge of the family finances.
- D. There is a moderate amount of alcohol use in the home.
- E. The client reports that the father was abusive during childhood.
Correct Answer: A,D,E
Rationale: Social isolation, alcohol use, and a history of childhood abuse are indicators of potential abuse, as they align with characteristics of violent families.
The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, 'What do you think about that?' Which is the best response by the nurse?
- A. Batterers never change, so it would be best for you to leave.
- B. If you don't leave, he'll think you're going to continue to endure his abuse.
- C. If you leave, maybe he'll see that he has to change his behavior.
- D. You may be in more physical danger after you leave him.
Correct Answer: D
Rationale: Leaving an abusive relationship can increase the risk of violence, so the nurse should inform the client of this danger to support safety planning.
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.
The nurse is working in the emergency department with a woman who was raped 1 hour ago. Which of the following is most important for the nurse to remember when planning care?
- A. The client should set aside any angry feelings until physical care is completed.
- B. Evidence collection according to procedures is not as important as treating the client's injuries.
- C. The nurse will need to make decisions for this client.
- D. The woman may feel threatened by some of the procedures.
Correct Answer: D
Rationale: Procedures like pelvic exams may feel invasive, so the nurse must be sensitive to the victim's potential feelings of re-traumatization.