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 Choices: 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 Choices: 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 day care. After observing poor hygiene, the nurse at the center talks with the patient’s adult child. This caregiver becomes defensive and says, “It takes all my time and energy to care for my mother. She’s awake all night. I never get any sleep.” Which nursing intervention has priority?
Answer Choices: 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 Choices: 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 Choices: 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 Choices: a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder c. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent and an adolescent son who has just begun dating
Answer: a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
Question: A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, “My father doesn’t like me. He calls me stupid all the time.” The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? (Select all that apply.)
Answer Choices: a. Parental sessions to teach child-rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support Correct Answers: a. Parental sessions to teach child-rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support
Answer: Not provided in source.
Question: A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, “My father doesn’t like me. He calls me stupid all the time.” The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? (Select all that apply.)
Answer Choices: a. Parental sessions to teach child-rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Foster placement of the children in foster care Correct Answers: a. Parental sessions to teach child-rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support
Answer: Not provided in source.
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 Choices: 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. Correct Answers: 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.
Answer: Not provided in source.
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 Choices: 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.” Correct Answers: 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.”
Answer: Not provided in source.
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 Choices: a. Victim b. Survivor c. Plaintiff d. Perpetrator
Answer: b. Survivor
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 Choices: a. Minimal b. Mild c. Moderate d. High
Answer: d. High
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 Choices: a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias
Answer: a. Confusion and disbelief
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 Choices: a. Somatic reaction b. Repression c. Projection d. Denial
Answer: d. Denial
Question: A child was abducted and raped. Which personal reaction by the nurse could interfere with the child’s care?
Answer Choices: a. Disgust b. Concern c. Empathy d. Compassion
Answer: a. Disgust
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 Choices: 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 rape victim asks an emergency department nurse, “Maybe I did something to cause this attack. Was it my fault?” Which response by the nurse is the most therapeutic?
Answer Choices: a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.
Answer: d. Support the victim to separate issues of vulnerability from blame.
Question: A rape victim tells the nurse, “I should not have been out on the street alone.” Which is the nurse’s most therapeutic response?
Answer Choices: a. “Rape can happen anywhere.” b. “Blaming yourself only increases your anxiety and discomfort.” c. “You believe this would not have happened if you had not been alone?” d. “You are right. You should not have been alone on the street at night.”
Answer: c. “You believe this would not have happened if you had not been alone?”