Answer Options:
a. Written instructions regarding legal procedures.
b. Provide referral information verbally and in writing.
c. Advise the victim to try not to think about the assault.
d. Offer to stay with the victim until stability is regained.
Answer: b. Provide referral information verbally and in writing.
Question: What feelings are most commonly experienced by nurses working with abusive families?
Answer Options:
a. Outrage toward the victim and sympathy for the abuser
b. Sympathy for the victim and anger toward the abuser
c. Unconcern for the victim and dislike for the abuser
d. Vulnerability for self and empathy with the abuser
Answer: b. Sympathy for the victim and anger toward the abuser
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: A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should provide what support?
Answer Options:
a. Assure the patient, “Before you leave you receive prophylactic treatment for sexually transmitted infections (STIs).”
b. Explain the need and importance of human immunodeficiency virus (HIV) testing in this situation.
c. Insist the patient complete the physical and emotional treatment that has been started.
d. Offer both verbal and written information about locally available legal resources.
Answer: b. Explain the need and importance of human immunodeficiency virus (HIV) testing in this situation.
Question: An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person’s underclothes. What is the priority action that staff members should focus on?
Answer Options:
a. Maintaining effective gas exchange
b. Preserving all rape evidence
c. Interviewing the friend for additional information
d. Determining whether any alcohol or drug were ingested
Answer: a. Maintaining effective gas exchange
Question: A rape victim tells the emergency department nurse, “I feel so dirty. Please let me take a shower before the doctor examines me.” How should the nurse respond to the request?
Answer Options:
a. Arrange for the patient to shower.
b. Explain that washing would destroy evidence.
c. Give the patient a basin of hot water and towels.
d. Instruct the victim to wash above the waist only.
Answer: b. Explain that washing would destroy evidence.
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: A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?
Answer Options:
a. Risk for injury
b. Post-trauma response
c. Disturbed thought processes
d. Risk for other-directed violence
Answer: d. Risk for other-directed violence
Question: A survivor in the long-term organization (delayed) phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement?
Answer Options:
a. The survivor expresses a need to regularly withdraw from social situations.
b. The survivor describes personal coping strategies for fearful situations.
c. The survivor uses increased activity to reduce feelings of fear.
d. The survivor expresses a deep desire to be with others.
Answer: b. The survivor describes personal coping strategies for fearful situations.
Question: A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” Which comments by the nurse will facilitate the interview with these parents? (Select all that apply.)
Answer Options:
a. “Tell me how you punish your children.”
b. “How do you stop your baby from crying?”
c. “Caring for four small children must be difficult.”
d. “Do you or your husband ever beat the children?”
e. “Calling children ‘stupid’ injures their self-esteem.”
Answer: a. “Tell me how you punish your children.”
b. “How do you stop your baby from crying?”
c. “Caring for four small children must be difficult.”
Question: A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority?
Answer Options:
a. Risk of intimate partner violence
b. Phobia of crowded places
c. Migraine headaches
d. Depressive symptoms
Answer: a. Risk of intimate partner violence
Question: A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? (Select all that apply.)
Answer Options:
a. Keep a cell phone fully charged.
b. Hide money with which to buy new clothes.
c. Have the telephone number for the nearest shelter.
d. Take enough toys to amuse the children for 2 days.
e. Secure a supply of current medications for self and children.
f. Determine a code word to signal children that it is time to leave.
g. Assemble birth certificates, Social Security cards, and licenses.
Answer: a. Keep a cell phone fully charged.
c. Have the telephone number for the nearest shelter.
e. Secure a supply of current medications for self and children.
f. Determine a code word to signal children that it is time to leave.
g. Assemble birth certificates, Social Security cards, and licenses.
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
Question: In what significant ways is the therapeutic environment different for a patient who has ingested lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
Answer Options:
a. For LSD ingestion, one person stays with the patient and provides verbal support.
b. For PCP ingestion, the patient is placed on one-on-one intensive supervision.
c. For LSD ingestion, continual moderate sensory stimulation is provided.
d. For LSD ingestion, the patient is placed in restraints.
Answer: a. For LSD ingestion, one person stays with the patient and provides verbal support
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 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 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: A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely?
Answer Options:
a. “She was very beautiful.”
b. “She wanted sex the sex.”
c. “I have issues with my mother.”
d. “I’ve been depressed for a long time.”
Answer: b. “She wanted sex the sex.”
Question: A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person’s level of anxiety?
Answer Options:
a. Minimal
b. Mild
c. Moderate
d. High
Answer: d. High
Question: A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, “I can’t talk about it. Nothing happened. I have to forget!” What is the person’s present coping strategy?
Answer Options:
a. Somatic reaction
b. Repression
c. Projection
d. Denial
Answer: d. Denial
Question: A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome?
Answer Options:
a. Confusion and disbelief
b. Decreased motor activity
c. Flashbacks and dreams
d. Fears and phobias
Answer: a. Confusion and disbelief
Question: When an emergency department nurse teaches a victim of rape about reactions that may occur during the long-term organization (delayed) phase, which symptoms should be included? (Select all that apply.)
Answer Options:
a. Development of fears and phobias
b. Decreased motor activity
c. Feelings of numbness
d. Flashbacks, dreams
e. Syncopal episodes
Answer: a. Development of fears and phobias
c. Feelings of numbness
d. Flashbacks, dreams
Question: When working with a patient beginning treatment for alcohol abuse, what is the nurse’s most therapeutic approach?
Answer Options:
a. Empathetic, supportive
b. Strong, confrontational
c. Skeptical, guarded
d. Cool, distant
Answer: a. Empathetic, supportive
Question: A nurse cares for a rape victim who was given flunitrazepam by the assailant. Which condition has priority?
Answer Options:
a. Dependence on others for positioning
b. Mental confusion
c. Hypoactivity of voluntary muscles
d. Signs and symptoms of respiratory depression
Answer: d. Signs and symptoms of respiratory depression
Question: An individual was killed during a store robbery 2 weeks ago. The widowed spouse, who was diagnosed 6 years ago with schizoaffective disorder, cries spontaneously when talking about the death. Which is the nurse’s most therapeutic comment?
Answer Options:
a. “I’m worried about how much you’re crying. You grief over your spouse’s death has gone on too long.”
b. “The unexpected death of your spouse must be painful. I’m glad you’re able to talk to me about your feelings.”
c. “This loss is harder to accept because of your mental illness. Let’s refer you for a partial hospitalization program.”
d. “Your crying shows you aren’t coping well. I made an appointment for you to see the psychiatrist for medication adjustment.”
Answer: b. “The unexpected death of your spouse must be painful. I’m glad you’re able to talk to me about your feelings.”