1. A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group
... [Show More] indicates an understanding of teaching?
A. "Children older than 3 are at greater risk for abuse"
B. "Substance use disorder does not increase the risk for violence."
C."Entering an intimate relationship increases the risk for violence."
D."Pregnancy increases the risk for violence toward the intimate partner." - 1. A. Children younger than 3 years of age are at an increased risk for abuse.
B. Substance use disorder increases the risk for violence.
C. Vulnerable persons are an increased risk for violence when they try to leave the relationship.
D. CORRECT: Pregnancy tends to increase the likelihood of violence toward the intimate partner.
2. A nurse is preparing to assess an infant who has shaken baby syndrome. Which of
the following is an expected finding? (Select all that apply.)
A. Sunken fontanels
B. Respiratory distress
C. Retinal hemorrhage
D. Altered level of consciousness E. Increase in head circumference - 2. A. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome.
B. CORRECT: Respiratory distress is an expected finding of shaken baby syndrome.
C. CORRECT: Retinal hemorrhage is an expected finding of shaken baby syndrome.
D. CORRECT: An altered level of consciousness is an expected finding of shaken baby syndrome due to intracranial trauma or hemorrhage.
E. CORRECT: An increase in head circumference is an expected finding of shaken baby syndrome.
3. A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible
abuse? (Select all that apply.)
A. Abrasions on knees
B. Round burn marks on forearms C. Mismatched clothing
D. Abdominal rebound tenderness E. Areas of ecchymosis on torso - 3. A. Minor injuries, such as abrasions, on the arms and legs are common in this age group.
B. CORRECT: Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse.
C. Mismatched clothing is consistent with the child's developmental age.
D. Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse.
E. CORRECT: Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse.
4. A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?
A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example
of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional abuse. - 4. A. Refusing to pay bills for a dependent is economic maltreatment, rather than neglect.
B. CORRECT: Physical violence occurs when physical pain or harm is directed toward another individual.
C. Striking an intimate partner or other individual is an example of physical, rather than sexual, violence. Sexual violence
occurs when sexual contact takes place without consent.
D. Failure to provide a stimulating environment for normal development is neglect, rather than emotional abuse.
5. A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?
A. Advise the client about the location of women's shelters.
B. Encourage the client to participate in a support group for survivors of abuse.
C. Implement case management to coordinate community
and social services.
D. Educate the client
about the use of stress management techniques. - 5. A. CORRECT: The greatest risk to this client is injury from intimate partner abuse; therefore, the priority action the nurse should
take is to assist the client with the development of a safety
plan that includes the identification of safe places to live.
B. The nurse should encourage participation in a support group. However, this does not address the greatest risk to the client and is therefore not the priority nursing action.
C. The nurse should implement case management. However, this does not address the greatest risk to the client and is therefore not the priority nursing action.
D. The nurse should educate the client about the use of stress management techniques. However, this does not address the greatest risk to the client and is therefore not the priority nursing action. [Show Less]