The interventions common to treatment plans for survivors include which of the following? Select all that apply.
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Solution
Answers: A, B, D
Identifying areas of control empowers the client. Supporting the client in the decisions he/she makes empowers the client and enhances the client’s current problem-solving ability. Establishing trust and rapport provides the client with an ally.
Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse?
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Solution
Antonia quits her job to move in and care for a parent with severe dementia.
In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parent. Caring for someone with severe dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse.
The caregivers in option B are the staff working in the personal care home; the adult child does not have primary responsibility and, therefore, would not be a high risk for severe stress and abuse.
In options C and D, the caregivers are receiving support and no one person has primary responsibility. This will decrease the risk for severe caregiver stress.
During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate?
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Solution
“Are you being threatened or hurt by your partner?”
The use of simple, direct question, asked in an emphatic manner, is best to validate the presence of an abusive situation.
Options B, C, and D: The other questions are indirect and may not lead to the discussion of an abusive situation.
Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply.
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Solution
Answers: A, B, C
These are all indications that a female child has been the victim of sexual abuse. Options D, E, and F are signs of physical abuse of a child, not sexual abuse.
Sheila tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn’t want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply.
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Solution
Answers: A, C, D, F
These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client’s feeling responsible for the abuse. Advising the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.
A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the young children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation?
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Solution
Impaired parenting, related to role reversal of mother and child.
The role of a 12-year-old child in a family should not be that of a parent. In this situation, the child and mother have reversed roles.
Options A, B, and D: There is no evidence that the child has delayed growth or development, the mother in this situation is not demonstrating signs of anxiety, and there is no evidence in this situation that the family is socially isolated.
Mariefer is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is:
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Solution
Implement measures to ensure the victim’s safety.
The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety.
Options A and B: The question is asking about implementing a specific nursing action, not assessing the problem or analyzing the family dynamics.
Option D: Teaching coping skill is important; however, the priority action involves ensuring safety.
Nurse Angela is working in the emergency department of Nurseslabs Medical Center. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first?
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Solution
Ensure privacy for interviewing the victim away from the abuser.
Privacy, away from the abuser, is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser (especially if she decides to return to the abusive situation).
Option A: In this situation, it is not the nurse’s responsibility to make the decision to report the abuse. However, whenever the injury is inflicted with a gun, knife, or other weapons, the nurse is obligated to report the abuse.
Option C: Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish rapport with the abuser.
Option D: The situation does not describe the abuser as currently violent or under the influence of substances; therefore requesting a security presence is inappropriate at this time.
Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse?
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Solution
The child has an interest in things of a sexual nature.
An 8-year-old child is in the latency phase of development; in this stage, the child’s interest in peers, activities, and school is the priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show an unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.
Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse’s priority intervention?
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Solution
Report suspicion of abuse to the proper authorities.
The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse.
Option A: The parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency.
Option B: Although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate.
Option C: Questioning the teacher may or may not provide validation of the nurse’s suspicions; regardless, this intervention does not ensure the child’s safety, which is the priority.
During a home visit to a family of three: a mother, father, and their child, The mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won’t get angry and refuse treatment. Which of the following is the best response of the nurse?
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Solution
The nurse commends the mother’s efforts and also contacts protective services.
The nurse would validate and reinforce the mother’s efforts to seek help; however, the nurse must also report the abuse to the appropriate protective services. The priority is to maintain the child’s safety.
Options A and B are inappropriate; the nurse is failing to provide for the child’s safety and is not following legal guidelines.
Option D: the nurse, is alienating the mother, as well as failing to follow legal guidelines and ensure the child’s safety.
During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except:
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Solution
Conflictual relationships of parents.
There is no evidence in this situation that the parents are in conflict; in fact, the mother is describing that the child “needed to be disciplined.” Often, in dysfunctional families, one child is singled out to be the victim and is the recipient of blame for problems.
Option B: The inconsistent communication pattern is that the child received conflicting messages regarding the preparation of food.
Option C: The rigid authoritarian roles demonstrated by the mothers indicate that the child needs discipline from the father. This is an example of a rigid role expectation of the father as a disciplinarian.
Option D: Also, the father used violence to retain the position of control.
A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned?
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Solution
Family violence affects every socioeconomic level.
Family violence occurs in all socioeconomic levels, races, religions, and cultural groups.
Option B: Although violence is associated with substance abuse, it is not the singular cause.
Option C: The statement that the family violence predominantly occurs in lower socioeconomic levels is false.
Option D: Abuse often occurs during pregnancy; about 23% of all pregnant women seeking prenatal care are victims of abuse.
Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case?
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Solution
History of the parent having been abused as a child
One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern.
Option A: Parents who are flexible in their roles are characteristic of healthy functioning, not abuse.
Options C and D: Single-parent households and a history of mental illness are not established risk factors for child abuse by a parent.