ch 36 Flashcards
A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care?
a. Medication to calm the perpetrator of the violence
b. A list of community resources
c. A referral for self-defense training
d. A referral to the victim’s religious advisor
ANS: B
Providing education that will address immediate safety needs for the patient is a priority action for the nurse. The nurse is not creating a plan for the perpetrator, nor is it the responsibility of the victim to receive medication for another person. Self-defense training does not meet the immediate safety concern for the patient and may aggravate the perpetrator further. Accessing support from a religious advisor is good for ongoing support, but it does not address the immediate need for safety information.
The nurse working at a women’s health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enters the room, the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be most important for the nurse to ask the patient?
a. “What brings you to the clinic today?”
b. “What can we do to help you today?”
c. “Do you feel safe in your current relationship?”
d. “Have you changed your diet lately?”
ANS: C
This patient is exhibiting signs of being abused. It is important to ask about the safety of the patient. General questions about her visit do not give an opportunity for the patient to discuss her safety needs. While a diet change can cause stomach problems, this assessment would be addressed once safety is addressed.
The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, “I don’t see any way to get away from my partner, and I can’t keep going on like this.” What assessment question is most important for the nurse to ask?
a. “Do you have any family in the area that can help?”
b. “Have you thought about hurting yourself or someone else?”
c. “Have you thought about moving to a different city?”
d. “Have you discussed this with anyone else?”
ANS: B
Depression and an increased risk of suicide are common outcomes from individuals experiencing interpersonal violence. It is critical that the nurse specifically assess for the risk of harm to the patient or to others during assessment. Asking if family or friends are available for support is good, but it is more important to assess for the safety concern of suicide or harm to others. It is not helpful to ask if a person who has stated that they don’t see a way out has thought of leaving—their comment indicates that they can’t see any solution. This situation is a high risk for suicide, or even homicide against the perpetrator.
The nurse is reviewing case files for children at risk for injury resulting in brain injury. Which child is at most risk for experiencing this type of violence?
a. A Caucasian, 6-month-old infant living with a single mother
b. An African-American, 24-month-old child living with her grandmother
c. A Mexican, 3-year-old child living in an inner city apartment
d. A Japanese, 8-year-old child living in a home with three generations of family
ANS: A
The highest incidence of traumatic brain injury occurs in Caucasian children aged birth to 1 year, and the abuse occurs most often from women.
Critical Thinking: A crisis intervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population?
a. There is not a good legal pathway to help persons in abusive relationships.
b. The abused person may return to the abusive home setting.
c. Hospital policies do not identify the legal care needed for abused persons.
d. Because length of care is short in the emergency department, there is little staff
can do for patients who have been abused.
ANS: B
Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all healthcare facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.
The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors?
a. Moving to a new community
b. Starting a new job
c. Becoming pregnant
d. The death of a grandfather
ANS: C
Abuse is not likely to decrease, and can often increase when a woman becomes pregnant. Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.
The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment? (Select all that apply.)
a. Reliving abuse incidents
b. Sleep disturbance
c. Overeating
d. Acting out behaviors
e. Intermittent fever
ANS: A, B, D
Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse.
