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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.
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The school nurse is teaching a health class about recognizing the signs of abusive relationships. The nurse describes the cycle of violence. The nurse would document effective teaching if the students identify the cycle of violence to be which of the following patterns? Select the order in which the events occur.
- A. Tension building
- B. Honeymoon period
- C. Violent behavior
- D. Period of remorse
Correct Answer: A,C,D,B
Rationale: The cycle of violence follows the pattern of tension building, violent behavior, period of remorse, and then a honeymoon period, repeating thereafter.
A coherent elderly woman has been financially and emotionally abused by her adult children for the past several years, but has failed to report the abuse to anyone. Which is the most likely reason that the woman neglects to report the abuse?
- A. She cannot claim abuse if there is no evidence of physical harm.
- B. Laws do not provide protection against abuse when the suspect(s) is/are family members.
- C. She has no financial resources to hire legal representation against her children.
- D. She is emotionally close to her children and does not want to bring them harm.
Correct Answer: D
Rationale: Elderly victims often avoid reporting abuse by family members due to emotional ties and a desire to protect them.
A woman has just presented at the emergency department after being raped. The initial nursing action would be to
- A. provide emotional support.
- B. refer her to a rape crisis hotline.
- C. encourage her to file charges immediately.
- D. perform a nursing history and physical as quickly as possible.
Correct Answer: A
Rationale: Providing emotional support is the initial priority to help the victim feel safe and regain control after a traumatic event.
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.
The nurse is involved in a community education program for new parents and plans to include information on child abuse. The nurse will teach the parents that the most common form of child abuse is which of the following?
- A. Neglect
- B. Physical abuse
- C. Sexual abuse
- D. Emotional abuse
Correct Answer: A
Rationale: Neglect is the most common form of child abuse, accounting for 64% of maltreatment cases.