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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.
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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.
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.
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 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.
Which characteristic of the abuser should the nurse look for when completing the family assessment of a victim of intimate partner violence?
- A. Encourages the partner to have a life outside the intimate relationship
- B. An inflated sense of self-esteem
- C. Needy and possessive of the partner
- D. An ability to feel remorse for the abuse
Correct Answer: C
Rationale: Abusers are typically needy, possessive, and view their partner as property, with low self-esteem rather than inflated self-esteem or genuine remorse.