Question 1

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I was never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child?

Accepted Answer

The child's statement reflects a negative self-view and internalization of negative feedback from parents, indicating chronic low self-esteem.

Question 2

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and a long-sleeved shirt. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action?

Accepted Answer

The nurse should document the injuries with a body map as it is important to have a detailed record of the injuries for legal and medical purposes. This documentation can be crucial for any future legal proceedings or interventions.

Question 3

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse?

Accepted Answer

The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.

Question 4

A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive?

Accepted Answer

The patient stated that her husband's family was abusive when he was growing up, which suggests that the history of family violence is a risk factor that contributed to the husband's abusive behavior. While the loss of employment and abuse of alcohol may contribute to stress and potentially exacerbate abusive behavior, they are not as predictive as a history of family violence. Poverty may also contribute to stress, but it is not specified in the scenario as a risk factor in this case.

Question 5

An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority?

Accepted Answer

The priority intervention is to secure additional resources for the mother's evening and night care to alleviate the caregiver's burden and ensure both the caregiver and the patient receive adequate support.

Question 6

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the teen should recognize that these behaviours often occur in which of the following adolescents?

Accepted Answer

These behaviors are often seen in adolescents who have been abused, as they may engage in risky behaviors as a coping mechanism or due to a lack of proper guidance and support.

Question 7

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care?

Accepted Answer

Expressing frustration verbally instead of physically indicates that the adult has learned to manage their emotions in a non-violent manner, which is a key goal in treating individuals with a history of physical violence.

Question 8

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of violence is likely?

Accepted Answer

The statement made by the child indicates emotional abuse, as it involves verbal harm and negative emotional impact.

Question 9

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

Accepted Answer

Strong negative feelings can cloud a nurse's ability to objectively assess the situation and make sound judgments, which is crucial when dealing with sensitive cases like family violence.

Question 10

What feelings are most commonly experienced by nurses working with abusive families?

Accepted Answer

Nurses working with abusive families often experience feelings of helplessness regarding the victim as they may not have the power to stop or prevent the abuse. At the same time, they may feel anger or frustration toward the abuser for perpetrating the abuse. These conflicting emotions can be challenging to navigate and manage for nurses.

Question 11

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse?

Accepted Answer

Bruises on extremities, especially in unusual patterns or locations, can be indicative of physical abuse, whereas the other conditions listed are common in children and not typically associated with abuse.

Question 12

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving?

Accepted Answer

The adult is experiencing the Honeymoon phase, which is characterized by apologies, gifts, and promises that the abuse will never happen again. This phase often creates a sense of hope that the relationship can improve and prevents the victim from leaving.

Question 13

What is a nurse's legal responsibility if child abuse or neglect is suspected?

Accepted Answer

Nurses are legally required to report any suspicions of child abuse or neglect to the appropriate authorities as per provincial or territorial regulations.

Question 14

An older adult with Lewy body dementia lives with family and attends a day care centre. A nurse there noticed the adult had a disheveled appearance, strong odour of urine, and bruises on the limbs and back. What type of violence might be occurring?

Accepted Answer

The disheveled appearance, strong odour of urine, and bruises on the limbs and back suggest physical abuse, which is a form of physical violence.

Question 15

An older adult with Alzheimer's disease lives with family in a rural area. During the week, the person attends a day care centre while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse?

Accepted Answer

Alzheimer's disease makes the patient most vulnerable to abuse due to cognitive impairments, which can lead to increased dependency and difficulty in communicating or reporting abuse.

Question 16

An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority?

Accepted Answer

The priority nursing diagnosis is "Risk for injury related to poor judgement, cognitive impairments, and inadequate supervision" because the patient's safety is at immediate risk due to the potential for falls and injuries.

Question 17

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions?

Accepted Answer

The initial focus should be on the survivor's risk for injury related to physical abuse from their partner. This is a safety concern that needs to be addressed immediately. The nurse should provide education on the importance of leaving an abusive relationship and offer resources for safety planning and escaping the abuse. The other options are important areas to address, but they are not the most urgent concern in this situation.

Question 18

A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge?

Accepted Answer

The patient should be aware of community resources for help, which can provide support and options for safety and assistance.

Question 19

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is the occupational health nurse's priority assessment?

Accepted Answer

The priority assessment for the occupational health nurse should be the physical injuries, as they are visible signs that may indicate the individual is experiencing abuse or violence, which requires immediate attention and intervention.

Question 20

Which referral will be most helpful for a woman who was severely beaten by her intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?

Accepted Answer

A women's shelter will provide immediate safety, support, and resources for a woman in this situation, addressing her urgent need for a safe place to stay.

Quiz 24: Interpersonal Violence: Child, Older Adult, and Intimate Partner Abuse