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Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?
- A. Support group
- B. Law enforcement
- C. Women's shelter
- D. Vocational counseling
Correct Answer: C
Rationale: Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. None of the other options proves the necessary level of safety.
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Which family scenario presents the greatest risk for family violence?
- A. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
- B. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder
- C. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care
- D. A single homosexual male parent and an adolescent son who has just begun dating girls
Correct Answer: A
Rationale: The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.
A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. The patient attends anger management classes. Which finding indicates success in this plan of care?
- A. The patient expresses frustration verbally instead of physically.
- B. The patient explains the rationale for behaviors to the victim.
- C. The patient identifies three personal strengths.
- D. The patient agrees to seek counseling.
Correct Answer: A
Rationale: The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?
- A. Self-awareness protects one's own mental health.
- B. Strong negative feelings interfere with assessment and judgment.
- C. Strong positive feelings lead to under involvement with the victim.
- D. Positive feelings promote the development of sympathy for patients.
Correct Answer: B
Rationale: Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.
What is a nurse's legal responsibility if child abuse or neglect is suspected?
- A. Discuss the findings with the child's teacher, principal, and school psychologist.
- B. Report the suspected abuse or neglect according to state regulations.
- C. Document the observations and speculations in the medical record.
- D. Continue the assessment.
Correct Answer: B
Rationale: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.
An 11-year-old child says, 'My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn.' Which nursing diagnosis applies to this child?
- A. Chronic low self-esteem, related to negative feedback from parents
- B. Deficient knowledge, related to interpersonal skills with parents
- C. Disturbed personal identity, related to negative self-evaluation
- D. Complicated grieving, related to poor academic performance
Correct Answer: A
Rationale: The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.