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The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 27-3, 4, 6, 8, 50 (Box 27-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

23. Family members describe the patient as “a difficult person who finds fault with others.” The patient verbally abuses nurses for their poor care. The most likely explanation lies in a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

ANS: C

Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 27-3, 4, 6, 23, 55 (Box 27-5) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient’s medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained.

24. A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse’s priority?

ANS: B

Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 27-20, 21, 52 (Box 27-3) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

Multiple Response

1. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.)

a. Stating the expectation that the patient will stay in control.

b. Asking the patient, “Do you want to go into seclusion?” c. Telling the patient, “You are behaving inappropriately.” d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

ANS: A, D, E

Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 27-14 to 16, 51 (Box 27-2) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

2. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.)

ANS: A, C, E

Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 27-15, 16, 19, 20 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Prefrontal cortex

3. Which central nervous system structures are most associated with anger and aggression? (Select all that apply.)

ANS: A, D, E

The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 27-4, 5 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity eBay: testbanks_and_xanax a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

4. Because an intervention was required to control a patient’s aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.)

ANS: A, C, D

The patient’s behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 27-21, 22

TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment eBay: testbanks_and_xanax

Chapter 28: Child, Older Adult, and Intimate Partner Violence

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

Multiple Choice

1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse?

a. “You are feeling violated because you thought you could trust your partner.” b. “I’m here for you. I want you to tell me about the bad things that happened to you.” c. “I was very worried about you. I knew you were living in a potentially violent situation.” d. “Abusers often target people who are passive. I will refer you to an assertiveness class.”

ANS: A

The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-12, 27

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Sexual b. Physical c. Emotional d. Economic

2. An 11-year-old reluctantly tells the nurse, “My parents don’t like me. They said they wish I was never born.” Which type of abuse is likely?

ANS: C

Examples of emotional abuse include having an adult demean a child’s worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-3, 17

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding 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

3. What feelings are most commonly experienced by nurses working with abusive families?

ANS: B

Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-21, 22, 51 (Table 28-3) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Self-awareness enhances the nurse’s advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

ANS: B

Strong negative feelings cloud the nurse’s judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to overinvolvement with victims rather than healthy transference.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-21, 22, 51 (Table 28-3) TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who a. have been abused. b. are attention seeking. c. have eating disorders. d. are developmentally delayed.

ANS: A

Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-6, 55 (Box 28-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Discuss the findings with the child’s parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

6. What is a nurse’s legal responsibility if child abuse or neglect is suspected?

ANS: C

Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-25, 66 (Box 28-7) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has a. complaints of abdominal pain. b. repeated middle ear infections. c. bruises on extremities. d. diarrhea.

ANS: C

Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-15, 16, 66 (Box 28-7) TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment 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

8. An 11-year-old says, “My parents don’t like me. They call me stupid and say they wish I were never born. It doesn’t matter what they think because I already know I’m dumb.” Which nursing diagnosis applies to this child?

ANS: A

The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child’s statements.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-24, 52 (Table 28-4) TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

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

ANS: D eBay: testbanks_and_xanax

The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-23, 24, 66 (Box 28-7) TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, “My partner beat me, but it was because I did not do the laundry.” What is the nurse’s next action?

ANS: D

Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-21, 36 (Case Study/Nursing Care Plan), 66 (Box 28-7)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

11. A patient tells the nurse, “My husband lost his job. He’s 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?

ANS: A

An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-12, 19, 52 (Table 28-4), 66 (Box 28-7)

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity a. Tension-building b. Acute battering c. Honeymoon d. Stabilization

12. An adult tells the nurse, “My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I’ve considered leaving but haven’t been able to bring myself to actually do it.” Which phase in the cycle of violence prevents this adult from leaving?

ANS: C

The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-10, 11

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

13. After treatment for a detached retina, a survivor of intimate partner abuse says, “My partner only abuses me when I make mistakes. I’ve considered leaving, but I was brought up to believe you stay together, no matter what happens.” Which diagnosis should be the focus of the nurse’s initial actions?

ANS: A

Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient’s safety.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 28-10, 11, 24, 52 (Table 28-4)

TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Safe, Effective Care Environment

14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, “I’ve considered leaving, but I made a vow and I must keep it no matter what happens.” Which outcome should be met before discharge? The patient will a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

ANS: B

The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser’s counseling may require weeks or months.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-27, 28, 32, 36 (Case Study/Nursing Care Plan)

TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Safe, Effective Care Environment a. Psychological b. Financial c. Physical d. Sexual

15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring?

ANS: C

Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse’s observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 28-3, 15, 16 TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. Multiple caregivers b. Alzheimer’s disease c. Living in a rural area d. Being part of a busy family

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

ANS: B

Older adults are at high risk for violence, particularly when there is significant dependency such as would be expected with dementia or other cognitive impairments. The incorrect responses are not identified as placing an individual at high risk.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 28-5 TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, “My mother often wanders at night. Last night she fell down the stairs.” Which nursing diagnosis has priority?

ANS: A

The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 28-24, 52 (Table 28-4) TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Safe, Effective Care Environment a. Teach the caregiver about the effects of sundowner’s syndrome. b. Secure additional resources for the mother’s evening and night care. c. Support the caregiver to grieve the loss of the mother’s cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

18. An older woman diagnosed with Alzheimer’s disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, “It takes all my energy to care for my mother. She’s awake all night. I never get any sleep.” Which nursing intervention has priority?

ANS: B

The patient’s caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 28-32 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

ANS: A

The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 28-36 TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity a. A support group b. A mental health center c. A women’s shelter d. Vocational counseling

20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?

ANS: C

Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-28, 63 (Box 28-6) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

Multiple Response

1. A 10-year-old 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 as priorities to stabilize the home situation? (Select all that apply.)

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

ANS: A, B, C

Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife’s admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-29, 30, 32 (Vignette), 36 (Case Study/Nursing Care Plan)

TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone 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. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.)

ANS: A, C, E, F, G

The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-27, 28, 63 (Box 28-6) TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment a. “Tell me how you discipline 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 spank your children?” e. “Calling children ‘stupid’ injures their self-esteem.”

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest 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 an interview with these parents? (Select all that apply.)

ANS: A, B, C

An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 28-12, 58 (Box 28-3) TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment