Question: Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse?

Answer Options:

a. Repeated middle ear infections
b. Severe colic
c. Bite marks
d. Croup

Answer: c. Bite marks

 

Question: 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?

Answer Options:

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

Answer: a. Chronic low self-esteem, related to negative feedback from parents

 

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

Answer Options:

a. Interpersonal relationships
b. Work responsibilities
c. Socialization skills
d. Physical injuries

Answer: d. Physical injuries

 

Question: An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse’s priority assessment question?

Answer Options:

a. “Do you drink excessively?”
b. “Did your partner beat you?”
c. “How did this happen to you?”
d. “What did you do to deserve this?”

Answer: c. “How did this happen to you?”

 

Question: An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse’s interview, the employee says, “My partner beat me, but it was because there are problems at work.” What should the nurse’s next action be?

Answer Options:

a. Notify the police.
b. Refer the employee to a shelter.
c. Notify the adult protective agency.
d. Document injuries with a body map.

Answer: d. Document injuries with a body map.

 

Question: A patient tells the nurse, “My husband is 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?

Answer Options:

a. History of family violence
b. Loss of employment
c. Abuse of alcohol
d. Poverty

Answer: a. History of family violence

 

Question: An adult tells the nurse, “My partner abuses me only when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I’ve considered leaving but haven’t been able to bring myself to actually do it.” Which phase in the cycle of violence prevents the patient from leaving?

Answer Options:

a. Tension building
b. Acute battering
c. Honeymoon
d. Recovery

Answer: c. Honeymoon

 

Question: After treatment for a detached retina, a victim of intimate partner violence says, “My partner only abuses me when intoxicated. I’ve considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me.” Which nursing diagnosis applies?

Answer Options:

a. Social isolation, related to lack of community support system
b. Risk for injury, related to partner’s physical abuse when intoxicated
c. Deficient knowledge, related to resources for escape from the abusive relationship
d. Disabled family coping, related to uneven distribution of power within a relationship

Answer: b. Risk for injury, related to partner’s physical abuse when intoxicated

 

Question: A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, “You stay together, no matter what happens.” Which outcome should be met before the patient leaves the emergency department? The patient will:

Answer Options:

a. limit contact with the abuser by obtaining a restraining (protective) order.
b. name two community resources that can be contacted.
c. demonstrate insight into the abusive relationship.
d. facilitate counseling for the abuser.

Answer: b. name two community resources that can be contacted.

 

Question: An older adult diagnosed with dementia lives with family and attends an adult day care center. A nurse at the center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse is the nurse most likely to suspect?

Answer Options:

a. Financial
b. Psychological
c. Physical
d. Sexual

Answer: c. Physical

 

Question: An older adult diagnosed with Alzheimer’s disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse?

Answer Options:

a. Dementia
b. Living in a rural area
c. Being part of a busy family
d. Being home only in the evening

Answer: a. Dementia

 

Question: An older adult, diagnosed with Alzheimer’s disease, lives with family and has multiple bruises. The home health nurse talks with the older adult’s daughter, who becomes defensive and says, “My mother often wanders at night. Last night she fell down the stairs.” Which nursing diagnosis has priority?

Answer Options:

a. Risk for injury, related to cognitive impairment and lack of caregiver supervision
b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation
c. Impaired verbal communication, related to brain impairment as evidenced by the confusion
d. Insomnia, related to cognitive impairment as evidenced by wandering at night

Answer: a. Risk for injury, related to cognitive impairment and lack of caregiver supervision

 

Question: An older adult diagnosed with dementia lives with family and attends an adult day care center. Observing poor hygiene, the nurse at the center talks with the family. The family says, “It takes all my time and effort to care for her.” Which intervention is most appropriate?

Answer Options:

a. Teach the caregiver more about the effects of dementia.
b. Secure additional resources for the mother’s evening and night care.
c. Support the caregiver to grieve the loss of the mother’s ability to function.
d. Teach the family how to give physical care more effectively and efficiently.

Answer: b. Secure additional resources for the mother’s evening and night care.

 

Question: 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?

Answer Options:

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.

Answer: a. The patient expresses frustration verbally instead of physically.

 

Question: 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?

Answer Options:

a. Support group
b. Law enforcement
c. Women’s shelter
d. Vocational counseling

Answer: c. Women’s shelter

 

Question: Which family scenario presents the greatest risk for family violence?

Answer Options:

a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child present a number of stressors.
b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with a defiant disorder.
c. A single mother with an executive position, a healthy child, and significant job demands.
d. A single homosexual male parent and an adolescent son who has just begun dating girls.

Answer: a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child present a number of stressors.

 

Question: A nurse works with a person who was raped 4 years ago. This person says, “It took a long time for me to recover from that horrible experience.” Which term should the nurse use when referring to this person?

Answer Options:

a. Victim
b. Survivor
c. Plaintiff
d. Perpetrator

Answer: b. Survivor