Nokea
The nurse is discussing expectations of raising a child with a pregnant teenager expecting her first baby. The father will not be a participant in the parenting. Which of the following statements made by the expectant mother would be of greatest concern to the nurse?
- A. I am going to rely on my sisters for a lot of help raising my baby.
- B. I was raised with very strict discipline.
- C. My child will love me unlike my parents ever did.
- D. I am not sure how I am going to pay for all the things my child will need.
Correct Answer: C
Rationale: Expecting a child to fulfill unmet emotional needs from childhood indicates unrealistic expectations, increasing the risk of potential abuse.
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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.
The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which of the following data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse?
- A. The parents appearing overprotective of the child
- B. Bruises over the child's bony prominences
- C. The injury occurring several days before the parents sought treatment
- D. Both parents reporting the exact same details pertaining to the injurious event
Correct Answer: C
Rationale: A delay in seeking treatment for a significant injury like a fractured femur is a warning sign of potential physical abuse.
Which of the following are common reasons why abused women remain with the abusive partner? Select all that apply.
- A. The abused person is personally and financially dependent on the abuser.
- B. The abused person has low self-esteem and defines her success as a person by the ability to make the relationship work.
- C. The abused person is convinced that she has been abusive toward the abuser at some point and that the abuse is her fault.
- D. The abused person believes that she is unable to function without her husband.
- E. The abused person is afraid that the abuser will kill her if she tries to leave.
Correct Answer: A,B,D,E
Rationale: Dependency, low self-esteem, belief in inability to function independently, and fear of lethal retaliation are common reasons abused women stay in abusive relationships.
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.
A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually abused repeatedly by her husband. Which of the following interventions would be appropriate in relation to this piece of data?
- A. Avoid discussing the abuse so as not to upset her.
- B. Encourage her to talk about feelings related to the abuse.
- C. Request an anxiolytic to reduce her anxiety levels.
- D. Help her explore her role in perpetuating the abuse.
Correct Answer: B
Rationale: Encouraging the client to discuss feelings about the abuse helps process the trauma and fosters healing, without implying victim responsibility.