Nokea
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.
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A guest lecturer from a treatment program for perpetrators of abuse is describing the program to a group of nursing students. The program uses cognitive behavioral techniques. Which of the following would the lecturer include as a focus of the program? Select all that apply.
- A. Identifying what the perpetrator thinks about before the incident
- B. Determining the perpetrator?s emotional and physical responses to the thoughts
- C. Exploring the perpetrator?s actions that eventually lead to violence
- D. Identifying the behaviors in the survivor that led to the violence
- E. Determining the extent of guilt or remorse experienced by the perpetrator
Correct Answer: A,B,C
Rationale: Cognitive behavioral techniques focus on identifying thoughts (A), emotional/physical responses (B), and actions (C) leading to violence to modify behavior. Blaming the survivor (D) is inappropriate, and assessing guilt/remorse (E) is secondary to addressing the cognitive-behavioral cycle.
The nurse is talking to a female client who is a survivor of intimate partner violence. The woman relates that her husband has been told that he has the characteristics of an antisocial personality disorder. The woman also informs the nurse that her husband has an extensive criminal record. The nurse interprets this information and suspects that the woman?s husband would most likely demonstrate which behavior?
- A. A risk for moderate to severe violence with people both within and outside his family
- B. Intermittent remorse for the violence and abuse that he commits
- C. Symptoms of depression along with harboring feelings of inadequacy
- D. Purposefully remain socially isolated from people other than those in his family
Correct Answer: A
Rationale: Antisocial personality disorder is characterized by a disregard for others' rights, often leading to a risk for moderate to severe violence both within and outside the family (A), especially given the husband's criminal record. Intermittent remorse (B) is unlikely, as lack of remorse is a hallmark of the disorder. Depression and inadequacy (C) are not typical, and social isolation (D) contradicts the manipulative social tendencies of antisocial personality.
A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?
- A. He threw me against the wall and started punching my face.
- B. He yells at me for not having dinner waiting for him when he came home.
- C. He calls me stupid and incompetent, asking himself why he ever married me.
- D. He tells me that he is sorry and that he will never hit me again.
Correct Answer: D
Rationale: Phase 3 of the cycle of violence, the honeymoon phase, involves the abuser expressing remorse and promising not to repeat the violence (D). Phase 1 (tension-building) includes yelling or verbal abuse (B, C), and phase 2 (acute battering) involves physical violence (A).
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 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.