Deck 55: Nursing Care of a Family in Crisis: Maltreatment and Violence in the Family

Question 1

A 3-month-old infant is diagnosed with failure to thrive. For which cause should the nurse include interventions when planning care for this patient?

A) A reaction to severe stress
B) Limited calcium metabolism
C) Poor parent-child relationship
D) Interference with gastrointestinal absorption

Answer 1

Poor parent-child relationship

Question 2

The nurse manager of an urban health care clinic is designing a series of presentations for staff to address the 2020 National Health Goals to reduce child maltreatment and intimate partner violence. Which topics should the manager include in these presentations? (Select all that apply.)

A) Caring for victims of rape
B) Indications of child neglect
C) Recognizing victims of violence
D) Environments where rape occurs
E) Manifestations of child maltreatment

Answer 2

Indications of child neglect
Recognizing victims of violence
Manifestations of child maltreatment

Question 3

At the completion of a health interview, the nurse is concerned that a newborn is at risk for maltreatment. Which observation caused the nurse to come to this conclusion?

A) Mother does not look at the baby.
B) Mother helps the nurse loosen the baby's clothing for a physical examination.
C) Mother explains that the husband helps with feeding the baby during the night.
D) Mother quickly changes a dirty diaper and uses personal supplies to cleanse the child.

Answer 3

Mother does not look at the baby.

Question 4

When beginning care for a victim of rape, the nurse asks the patient to "talk about what happened" to her. For which nursing diagnosis is the nurse using this approach?

A) Anxiety related to recent rape
B) Fear related to repeated episodes of maltreatment
C) Disabling family coping related to recent rape of family member
D) Risk for other-directed violence related to admitted poor self-control

Question 5

The nurse is visiting the home of a family with a previous history of physical neglect. Which observation indicates that interventions have not been successful?

A) The mother feeds the children a total vegetarian diet.
B) The father encourages male children to play high school football.
C) The mother worries that immunizations will be painful for the children.
D) The father allows the children to stay home from school whenever they desire.

Question 6

While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home?

A) Scolding one child for playing with matches
B) Belittling the child in front of the nurse and other siblings
C) Punishing one child for crossing the street without assistance
D) Asking one child to perform a song on the piano for the nurse

Question 7

The mother of a toddler experiencing stomach pain insists that the child be admitted to find out the cause of the pain. The child has been in the emergency room three other times in the past 6 months for the same complaint. What other information should alert the nurse to investigate the situation further?

A) The mother is a single parent.
B) The mother is in nursing school.
C) The child has a 1-year-old sister.
D) The child verbalizes abdominal pain when the mother is not present.

Question 8

The school district is planning an educational program for high school students to reduce the incidence of rape. When planning this program, which information should the school nurse include? (Select all that apply.)

A) Carry a weapon or mace at all times.
B) When leaving school after dark, walk on the street.
C) Lock car doors when waiting in it and after parking it.
D) Keep all doors and windows locked when home alone.
E) Avoid taking illegal substances when in social situations.

Question 9

Which patient's physical assessment finding of a school-age child should the nurse question as a potential indication of abuse?

A) A thin, tall appearance
B) A scald burn on the chest
C) A maculopapular rash on the buttocks
D) Linear abrasions on his ankles and wrists

Question 10

The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for this child's care?

A) Birth mother has stopped visiting the child.
B) Birth father comes by the home to bring toys.
C) Child eagerly takes a bottle and is gaining weight.
D) Child is crying and has bruises over the lower legs.

Question 11

The nurse gives a preschool-age child two anatomically correct dolls to play with in efforts to determine if the child has been sexually abused. Which observation indicates to the nurse that this is a possibility?

A) Child inserts the male doll's penis into the female doll's mouth.
B) Child holds both dolls together to make them walk together holding hands.
C) Child takes off the dolls' clothing, laughs, and then puts the clothes back on.
D) Child holds dolls facing each other and moves the arms so that the dolls hug.

Question 12

The nurse in the emergency department is documenting the appearance and care provided to a victim of rape. Which statement should the nurse include when documenting this care?

A) Victim has blood stains on both inner thighs.
B) Victim claims to be raped but does not appear fearful or traumatized.
C) Victim handling the incident well by talking with the male police officers.
D) Victim wearing provocative low-cut lace blouse and bra and short skirt with high heels.

Question 13

The nurse decides to spend extra time with a pregnant patient in the prenatal clinic in efforts to determine if the patient is a victim of intimate partner violence. What caused the nurse to make this plan prior to assessing the patient?

A) Patient chatting with another patient in the waiting room
B) Patient wearing a long sleeved jacket on a hot summer day
C) Patient periodically looking at a wrist watch to check the time
D) Patient unconsciously rubbing the abdomen while reading a magazine

Question 14

The community nurse is visiting a victim of rape at home. Which observation indicates that crisis intervention goals have not been met?

A) Husband hopes to meet the rapist in a back alley 1 day.
B) Victim and husband sit with the nurse at the kitchen table and discuss feelings.
C) Victim states that intimate relationship with the husband has resumed without incident.
D) Husband holds the victim's hand and expresses endearing terms while the victim smiles.

Question 15

During a routine well-child visit, the mother of a preadolescent patient asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overtly admiring the child when playing outdoors. What information should the nurse provide to the mother? (Select all that apply.)

A) Child reports abdominal pain.
B) Child has a change in school performance.
C) Child demonstrates anxiety or trouble sleeping.
D) Child does not want to be left alone with a certain adult.
E) Child spends a great deal of time with peer-group friends.