Module 32 Violence: Nursing: A Concept-Based Approach To Learning, 2e (Pearson)

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 32 Violence
The Concept of Violence
1) A young client is brought into the Emergency Department by a friend who says the client was
"beat up" at school. The client is reluctant to provide the names of parents or a home address.
What should the nurse suspect has occurred with this client?
A) The client does not want the individual who did the beating to get in trouble.
B) The client does not know his parents.
C) The client does not want the school to get in trouble.
D) The client is a victim of interpersonal violence.
Answer: D
Explanation: A) Although the nurse may initially believe that the client is telling the truth about
being beaten up at school, the client's reluctance to provide parents' names or address could
suggest the client is a victim of interpersonal violence. Reluctance to provide personal
information could mean fear of further abuse. It is unlikely that the client does not know his
parents. It is also unlikely that the client does not want to get the school or the individual who did
the beating in trouble.
B) Although the nurse may initially believe that the client is telling the truth about being beaten
up at school, the client's reluctance to provide parents' names or address could suggest the client
is a victim of interpersonal violence. Reluctance to provide personal information could mean fear
of further abuse. It is unlikely that the client does not know his parents. It is also unlikely that the
client does not want to get the school or the individual who did the beating in trouble.
C) Although the nurse may initially believe that the client is telling the truth about being beaten
D) Although the nurse may initially believe that the client is telling the truth about being beaten
Page Ref: 1954
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common assessment procedures used to examine violent
behavior across the life span.
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2) A client with a walking disability tells the nurse that going out alone at night is not an option
for fear of being a target for a crime. The nurse realizes this client has identified a:
A) Predisposing factor.
B) Risk factor.
C) Vulnerability factor.
D) Precipitating factor.
Answer: C
Explanation: A) Vulnerability factors increase one's risk of being a victim of violence. The
client with a walking disability avoids the possibility of a crime by not going out alone at night.
Predisposing factors are those that increase one's risk of violent victimization or perpetration of
violence. Risk factors increase the potential that one will perpetrate violence on others.
Precipitating factors are those that give rise to a specific incident of violence.
B) Vulnerability factors increase one's risk of being a victim of violence. The client with a
walking disability avoids the possibility of a crime by not going out alone at night. Predisposing
factors are those that increase one's risk of violent victimization or perpetration of violence. Risk
factors increase the potential that one will perpetrate violence on others. Precipitating factors are
those that give rise to a specific incident of violence.
C) Vulnerability factors increase one's risk of being a victim of violence. The client with a
D) Vulnerability factors increase one's risk of being a victim of violence. The client with a
Page Ref: 1954
Learning Outcome: 2. Examine the relationship between violence and other concepts/systems.
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3) A client is admitted with injuries sustained from a domestic dispute. When planning care, the
nurse will include which short-term interventions?
Select all that apply.
A) Explore options for self-development.
B) Improve quality of life by increasing self-esteem.
C) Explore options for help.
D) Convey safety.
E) Determine immediacy of danger.
Answer: C, D, E
Explanation: A) Short-term interventions for abuse include determining the immediacy of
danger, conveying that the client has the right to be safe, and exploring options for help.
Exploring options for self-development and improving the quality of life by increasing self-
esteem are long-term interventions for abused adults.
B) Short-term interventions for abuse include determining the immediacy of danger, conveying
that the client has the right to be safe, and exploring options for help. Exploring options for self-
development and improving the quality of life by increasing self-esteem are long-term
interventions for abused adults.
C) Short-term interventions for abuse include determining the immediacy of danger, conveying
D) Short-term interventions for abuse include determining the immediacy of danger, conveying
E) Short-term interventions for abuse include determining the immediacy of danger, conveying
Page Ref: 1962-1963
Cognitive Level: Applying
Nursing Process: Planning
Learning Outcome: 3. Identify commonly occurring alterations in violent acts and their related
therapies.
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4) After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic
violence. What should occur next?
A) Conduct a team assessment.
B) Medicate for anxiety as prescribed.
C) Notify the police.
D) Treat the injuries.
Answer: A
Explanation: A) If the nursing assessment reveals possible domestic violence, a team assessment
needs to take place. The police may need to be notified later. The extent of injuries will dictate
when they should be treated. The degree of anxiety will also determine whether the client needs
medication.
B) If the nursing assessment reveals possible domestic violence, a team assessment needs to take
place. The police may need to be notified later. The extent of injuries will dictate when they
should be treated. The degree of anxiety will also determine whether the client needs medication.
C) If the nursing assessment reveals possible domestic violence, a team assessment needs to take
D) If the nursing assessment reveals possible domestic violence, a team assessment needs to take
Page Ref: 1960
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in violence.
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5) The nurse is caring for a client that is the victim of domestic violence and is visited by the
spouse in the hospital. What should the nurse do to support the client?
A) Call the police to have the spouse arrested for assault.
B) Refuse to permit the spouse to visit with the client.
C) Call security to have the spouse removed.
D) Ask the client if there is anything that is needed at this time.
Answer: D
Explanation: A) The nurse needs to maintain a nonjudgmental attitude when caring for victims
of abuse and their family members. The nurse should ask the client if there is anything that is
needed at this time. The nurse should not refuse to let the spouse visit unless it is the client's wish
to do so. The nurse should not contact security or the police.
B) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and
their family members. The nurse should ask the client if there is anything that is needed at this
time. The nurse should not refuse to let the spouse visit unless it is the client's wish to do so. The
nurse should not contact security or the police.
C) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and
D) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and
Page Ref: 1963
Nursing Process: Implementation
Learning Outcome: 6. Explain prevention efforts for violence.
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6) When caring for an abused child, what should the nurse do?
A) Ask the child what he did to cause his parents to beat him so badly.
B) Tell the child that the individual who hurt them is a bad person.
C) Follow protocols for mandatory reporting.
D) Remind the child that he did nothing wrong.
E) Ask the child what really happened.
Answer: C, D
Explanation: A) The priority nursing consideration regarding the abused child is to ensure the
immediate safety of the child. Beyond that, the abused child needs to be encouraged to talk about
the abuse but must also be protected from having to provide multiple reports. The nurse working
with the abused child needs to say that he or she believes the child's story; the nurse also must
reassure the child that he or she has done nothing wrong. The nurse should avoid making
negative comments about the abuser and must follow established protocols for mandatory
reporting, documentation, and use of available support services.
B) The priority nursing consideration regarding the abused child is to ensure the immediate
safety of the child. Beyond that, the abused child needs to be encouraged to talk about the abuse
but must also be protected from having to provide multiple reports. The nurse working with the
abused child needs to say that he or she believes the child's story; the nurse also must reassure
the child that he or she has done nothing wrong. The nurse should avoid making negative
comments about the abuser and must follow established protocols for mandatory reporting,
documentation, and use of available support services.
C) The priority nursing consideration regarding the abused child is to ensure the immediate
D) The priority nursing consideration regarding the abused child is to ensure the immediate
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E) The priority nursing consideration regarding the abused child is to ensure the immediate
Page Ref: 1962
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in violence.
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7) The nurse is working in orthopedics and is discharging Mrs. Snell, who was admitted for
surgery for a compound ulnar fracture that occurred during a conflict with her husband. When
she says, "I hope this cast comes off before summer. Last night my husband promised me he is
going to take me to Hawaii this summer. After he broke my jaw we went to Rome." What does
the nurse assess Mrs. Snell is anticipating?
A) A tension phase
B) An abusive phase
C) A honeymoon phase
D) A stop to the violence
E) Reconciliation and healing
Answer: C
Explanation: A) The tension phase of the cycle of violence occurs when communication fails
and tension builds. The abusive phase occurs when there is a violent incident. The honeymoon
phase occurs when the aggressor shows love and affection. The cycle of violence will continue
unless intervention occurs, and there is no reason for Mrs. Snell to expect it will stop or
anticipate reconciliation and healing.
B) The tension phase of the cycle of violence occurs when communication fails and tension
builds. The abusive phase occurs when there is a violent incident. The honeymoon phase occurs
when the aggressor shows love and affection. The cycle of violence will continue unless
intervention occurs, and there is no reason for Mrs. Snell to expect it will stop or anticipate
reconciliation and healing.
C) The tension phase of the cycle of violence occurs when communication fails and tension
D) The tension phase of the cycle of violence occurs when communication fails and tension
E) The tension phase of the cycle of violence occurs when communication fails and tension
Page Ref: 1955
Client Need: Health Promotion and Maintenance
Learning Outcome: 1. Summarize the physiology of aggression and violence.
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8) A 19-year-old female student is brought into the Emergency Department by her roommate.
The roommate says, "She came home from a party at her boyfriend's house and said that he
raped her." Which assessment techniques are appropriate?
A) Inquire how many sexual partners she has had.
B) Offer to use a rape evidence collection kit.
C) Ask her if she has ever had a sexually transmitted infection.
D) Assess for the presence of an intact hymen.
E) Ask her if she led her boyfriend on in any way.
Answer: B, D
Explanation: A) It is inappropriate to ask her how many sexual partners she has had, if she has
ever had a sexually transmitted infection, or if she led her boyfriend on. You should offer to use
a rape evidence collection kit. It is also inappropriate to assess for the presence of an intact
hymen.
B) It is inappropriate to ask her how many sexual partners she has had, if she has ever had a
sexually transmitted infection, or if she led her boyfriend on. You should offer to use a rape
evidence collection kit. It is also inappropriate to assess for the presence of an intact hymen.
C) It is inappropriate to ask her how many sexual partners she has had, if she has ever had a
D) It is inappropriate to ask her how many sexual partners she has had, if she has ever had a
E) It is inappropriate to ask her how many sexual partners she has had, if she has ever had a
Page Ref: 1960
Client Need: Physiological Integrity
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine if an individual has
been the victim of violence.
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9) The school nurse is leading a discussion on violence with a group of teens. Which factors
could the school nurse indicate to the teens as protective factors that may decrease the risk of
violence?
A) Involvement in the community
B) Participation in family activities
C) Residing in an impoverished community
D) Academic failures at a young age
E) Success in school
Answer: A, B, E
Explanation: A) Involvement in the community, participation in family activities, and success in
school are all examples of protective factors. Protective factors decrease the risk of violence
perpetration and victimization. Residing in an impoverished community is a predisposing factor.
Academic failure at a young age is an influential factor.
B) Involvement in the community, participation in family activities, and success in school are all
examples of protective factors. Protective factors decrease the risk of violence perpetration and
victimization. Residing in an impoverished community is a predisposing factor. Academic
failure at a young age is an influential factor.
C) Involvement in the community, participation in family activities, and success in school are all
D) Involvement in the community, participation in family activities, and success in school are all
E) Involvement in the community, participation in family activities, and success in school are all
Page Ref: 1959
Nursing Process: Teaching and Learning
Learning Outcome: 6. Explain prevention efforts for violence.
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10) A client is brought into the Emergency Department after being in a motor vehicle accident.
The client has suffered traumatic injury that may involve multiple body systems. What is the
priority assessment for the nurse?
A) Breathing and ventilation
B) Circulation with hemorrhage control
C) Airway maintenance with cervical spine protection
D) Disability and neurological assessment
Answer: C
Explanation: A) When caring for the trauma victim the nurse must always prioritize
assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's
first concern is airway maintenance with cervical spine protection.
B) When caring for the trauma victim the nurse must always prioritize assessments, with the
ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern is airway
maintenance with cervical spine protection.
C) When caring for the trauma victim the nurse must always prioritize assessments, with the
D) When caring for the trauma victim the nurse must always prioritize assessments, with the
Page Ref: 1960
Client Need Sub: Physiological Adaptation
Learning Outcome: 4. Differentiate common assessment procedures used to examine violent
behavior across the life span.
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11) The Emergency Department nurse is caring for a client with multiple injuries. The client has
had a diagnostic peritoneal lavage to determine the presence of blood in the peritoneal cavity.
Which result would indicate to the nurse that the diagnostic test is considered positive?
A) The solution returns pale pink and is found to have a white blood cell count of < 500.
B) The solution returns pale pink and is found to have a red blood cell count of 50,000 mm3.
C) The solution returns pink and is found to have bile, food, or feces.
D) The solution returns clear and is found to have a red blood cell count of 90,000 mm3.
Answer: C
Explanation: A) If the solution returns pink and is found to have a red blood cell count of
100,000 mm3, a white blood cell count of > 500, or bile, food, or feces, the test is considered
positive and the client is taken to the operating room for exploratory surgery.
B) If the solution returns pink and is found to have a red blood cell count of 100,000 mm3, a
white blood cell count of > 500, or bile, food, or feces, the test is considered positive and the
client is taken to the operating room for exploratory surgery.
C) If the solution returns pink and is found to have a red blood cell count of 100,000 mm3, a
D) If the solution returns pink and is found to have a red blood cell count of 100,000 mm3, a
Page Ref: 1961
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine if an individual has
been the victim of violence.
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Exemplar 32.1 Abuse
1) A child is admitted to the hospital with physical injuries. What would indicate to the nurse that
the child is a victim of child abuse?
A) Confusion
B) Missing teeth
C) Inappropriate response to pain
D) Abrasions to the mouth, lips, and genitalia
E) Dehydration
Answer: B, C, D
Explanation: A) Clinical manifestations of child abuse include abrasions to the mouth, lips, and
genitalia; missing teeth; and inappropriate responses to pain. Dehydration and confusion are
manifestations of elder abuse.
B) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia;
missing teeth; and inappropriate responses to pain. Dehydration and confusion are manifestations
of elder abuse.
C) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia;
of elder abuse.
D) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia;
of elder abuse.
E) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia;
of elder abuse.
Page Ref: 1972
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of abuse.
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2) What does the nurse recognize as risk factors for the abuse of a 2-year-old client?
A) The child has bruises on the knees and shins.
B) The child's parents are married.
C) The child is less than 3 years old.
D) The child is deaf.
E) The child's parents are unemployed and receive medical assistance.
Answer: C, D, E
Explanation: A) Risk factors for child abuse include poverty, age less than 3 years, and child
disability or condition that requires a great deal of care. Marriage of the parents and bruises on
the knees and shins are not risk factors for abuse.
B) Risk factors for child abuse include poverty, age less than 3 years, and child disability or
condition that requires a great deal of care. Marriage of the parents and bruises on the knees and
shins are not risk factors for abuse.
C) Risk factors for child abuse include poverty, age less than 3 years, and child disability or
D) Risk factors for child abuse include poverty, age less than 3 years, and child disability or
E) Risk factors for child abuse include poverty, age less than 3 years, and child disability or
Page Ref: 1967-1968
Learning Outcome: 2. Identify risk factors and prevention methods associated with abuse.
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3) A young female client comes into the Emergency Department with vague physical symptoms
and does not make eye contact with the nurse during the interview. Which question should the
nurse ask to gain understanding of the client's situation?
A) "What kind of problems are you having?"
B) "Can you tell me what's been going on in your life lately?"
C) "Is someone hurting you?"
D) "Can you explain what your family life is like?"
Answer: C
Explanation: A) A nurse who works with women should explicitly ask if the young adult is
frightened or hurt by someone she knows. It is essential that nurses make assessment for
domestic violence part of their routine. Generalized questions about family life, life problems, or
events in the individual's life only allow for the topic of domestic abuse to be skirted and perhaps
avoided altogether. The nurse needs to address it pointedly and directly.
B) A nurse who works with women should explicitly ask if the young adult is frightened or hurt
by someone she knows. It is essential that nurses make assessment for domestic violence part of
their routine. Generalized questions about family life, life problems, or events in the individual's
life only allow for the topic of domestic abuse to be skirted and perhaps avoided altogether. The
nurse needs to address it pointedly and directly.
C) A nurse who works with women should explicitly ask if the young adult is frightened or hurt
D) A nurse who works with women should explicitly ask if the young adult is frightened or hurt
Page Ref: 1965
Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across
the life span for individuals who have been abused.
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4) A client with a long history of experiencing domestic violence tells the nurse, "There is no
way out for me; this situation will never change." What nursing diagnosis would be most
appropriate?
A) Powerlessness
B) Risk for Other-Directed Violence
C) Ineffective Health Maintenance
D) Chronic Low Self-Esteem
Answer: A
Explanation: A) Powerlessness is indicated when the client feels an inability to change the
pattern or to leave the situation. The victim may experience health maintenance problems as a
result of experiencing domestic violence; however, this is not the primary diagnosis. Some
victims will experience self-esteem issues, which are secondary to their feeling of having little or
no control over their lives. The client is not at high risk for other-directed violence but is rather at
high risk to experience it.
B) Powerlessness is indicated when the client feels an inability to change the pattern or to leave
the situation. The victim may experience health maintenance problems as a result of
experiencing domestic violence; however, this is not the primary diagnosis. Some victims will
experience self-esteem issues, which are secondary to their feeling of having little or no control
over their lives. The client is not at high risk for other-directed violence but is rather at high risk
to experience it.
C) Powerlessness is indicated when the client feels an inability to change the pattern or to leave
to experience it.
D) Powerlessness is indicated when the client feels an inability to change the pattern or to leave
to experience it.
Page Ref: 1971
Nursing Process: Diagnosis
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual who
has been abused.
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5) What would the nurse's care plan include for a client who has experienced spousal abuse
resulting in several fractures?
A) Assist the client to devise a safety or escape plan.
B) Encourage the client to take charge of the situation.
C) Offer to contact outpatient services if the client promises not to return home after discharge.
D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A
Explanation: A) A client who has been victimized by a partner should have a safety plan. This
has the highest priority as the client's life is in danger. The client has no control over the partner,
and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging
the client to take charge is too general a statement to be helpful; the client needs specific tools to
develop a safety plan. It may not be safe and feasible for the client to leave the situation right
away, and resources should not be withheld if a client is unable to promise not to return home.
B) A client who has been victimized by a partner should have a safety plan. This has the highest
priority as the client's life is in danger. The client has no control over the partner, and suggesting
that the couple needs to see a therapist may escalate the situation. Encouraging the client to take
charge is too general a statement to be helpful; the client needs specific tools to develop a safety
plan. It may not be safe and feasible for the client to leave the situation right away, and resources
should not be withheld if a client is unable to promise not to return home.
C) A client who has been victimized by a partner should have a safety plan. This has the highest
D) A client who has been victimized by a partner should have a safety plan. This has the highest
Page Ref: 1974
Learning Outcome: 6. Plan evidence-based care for an individual who has been abused and his
or her family in collaboration with other members of the healthcare team.
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6) A client who has experienced domestic violence in the past has decided to stop participating in
counseling. Which client statement would indicate that therapy has been effective?
A) "Everyone knows what my problems are, and there is nothing I can do about it."
B) "I am functioning fine now but I know that when problems come up again, I will ask for
help."
C) "My friends tell me that I have improved so this is a good time to stop."
D) "It is so draining to deal with the same painful issues all of the time."
Answer: B
Explanation: A) The client acknowledging that future problems will come up indicates that the
client has gained insight into problems. The client's willingness to ask for help shows that the
client is prepared to continue with counseling when new problems arise. Stating that the process
is draining and painful suggests that little progress has been made and that the client is looking to
avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of
treatment on the statements of others places emphasis on others and not on self-evaluation.
B) The client acknowledging that future problems will come up indicates that the client has
gained insight into problems. The client's willingness to ask for help shows that the client is
prepared to continue with counseling when new problems arise. Stating that the process is
draining and painful suggests that little progress has been made and that the client is looking to
C) The client acknowledging that future problems will come up indicates that the client has
D) The client acknowledging that future problems will come up indicates that the client has
Page Ref: 1974
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual who has been abused.
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7) A client recovering from injuries obtained from a domestic dispute asks to attend Mass at the
hospital chapel. The nurse understands that it is important for the client to:
A) Find a distraction from the injuries.
B) Attend to spiritual needs in order to deal with what has happened.
C) Show an interest in what is going on in the world.
D) Get back to a normal routine as soon as possible.
Answer: B
Explanation: A) The nurse understands the importance of spiritual support in the recovery
process. The client may be struggling with questions or experiencing feelings of rage and grief.
This is an important component of the process that will help the client move closer to the healing
phase. The client may wish to attend Mass for the other reasons given, but the nurse knows that
these are not as significant to the recovery process.
B) The nurse understands the importance of spiritual support in the recovery process. The client
may be struggling with questions or experiencing feelings of rage and grief. This is an important
component of the process that will help the client move closer to the healing phase. The client
may wish to attend Mass for the other reasons given, but the nurse knows that these are not as
significant to the recovery process.
C) The nurse understands the importance of spiritual support in the recovery process. The client
D) The nurse understands the importance of spiritual support in the recovery process. The client
Page Ref: 1974
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual who has been abused.
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8) What would be appropriate interventions for a victim of interpersonal violence?
A) Educating the client on how to avoid future incidents of violence
B) Distracting the client to avoid overwhelming feelings about the situation
C) Using a supportive, nurturing approach
D) Helping the client identify intra- and interpersonal strengths
E) Maintaining objectivity and offering short, to-the-point responses
Answer: C, D
Explanation: A) The nurse should use a supportive, nurturing approach because it is important
for victims of interpersonal violence to feel supported and cared for in order to develop trust and
work through their issues. The nurse should also help the client identify intra- and interpersonal
strengths because recognition of strengths will decrease feelings of helplessness. Educating the
client on how to avoid future incidents of violence is not therapeutic and implies that the incident
might have been the client's fault. Distracting the client will prolong the grieving process, and the
client will be left with unresolved conflicted feelings. Maintaining objectivity and providing
short responses discourages communication and does not offer the client the empathy and
support that are needed.
B) The nurse should use a supportive, nurturing approach because it is important for victims of
interpersonal violence to feel supported and cared for in order to develop trust and work through
their issues. The nurse should also help the client identify intra- and interpersonal strengths
because recognition of strengths will decrease feelings of helplessness. Educating the client on
how to avoid future incidents of violence is not therapeutic and implies that the incident might
have been the client's fault. Distracting the client will prolong the grieving process, and the client
will be left with unresolved conflicted feelings. Maintaining objectivity and providing short
responses discourages communication and does not offer the client the empathy and support that
are needed.
C) The nurse should use a supportive, nurturing approach because it is important for victims of
are needed.
D) The nurse should use a supportive, nurturing approach because it is important for victims of
are needed.
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E) The nurse should use a supportive, nurturing approach because it is important for victims of
are needed.
Page Ref: 1974
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9) An elderly client is brought into the Emergency Department for a recent fall. The nurse
suspects elder abuse. What are clinical manifestations of elder abuse?
A) Poor hygiene
B) Dehydration
C) Intracranial trauma
D) Fecal impaction
E) Dislocations
Answer: A, B, D, E
Explanation: A) The nurse suspecting elder abuse would assess for clinical manifestations
associated with elder abuse. Some of those clinical manifestations are: constant hunger or
malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures,
sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse;
however, it is a clinical manifestation of child abuse.
B) The nurse suspecting elder abuse would assess for clinical manifestations associated with
elder abuse. Some of those clinical manifestations are: constant hunger or malnutrition, poor
hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or
dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it
is a clinical manifestation of child abuse.
C) The nurse suspecting elder abuse would assess for clinical manifestations associated with
D) The nurse suspecting elder abuse would assess for clinical manifestations associated with
E) The nurse suspecting elder abuse would assess for clinical manifestations associated with
Page Ref: 1972
direct and indirect causes of abuse.
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10) The nurse is completing a morning assessment on a 68-year old Asian client. Assessment
findings reveal circular red welts over the client's upper back with several bruised areas. What
would be an appropriate action for the nurse?
A) Contact adult protective services.
B) Call the physician immediately.
C) Assess the client's spiritual beliefs.
D) Contact the client's family.
Answer: C
Explanation: A) The most appropriate action for the nurse at this time is to assess the client's
spiritual beliefs. The practice of cupping is generally practiced by many Asian cultures, as well
as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the
skin, and then using heat to create suction; often this is performed to promote blood flow and
overall healing. The result of the procedure can be circular red welts or even dark bruising,
which are often found along the individual's back. This treatment is not abusive in nature, but
rather a form of healing.
B) The most appropriate action for the nurse at this time is to assess the client's spiritual beliefs.
The practice of cupping is generally practiced by many Asian cultures, as well as individuals
who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then
using heat to create suction; often this is performed to promote blood flow and overall healing.
The result of the procedure can be circular red welts or even dark bruising, which are often found
along the individual's back. This treatment is not abusive in nature, but rather a form of healing.
C) The most appropriate action for the nurse at this time is to assess the client's spiritual beliefs.
D) The most appropriate action for the nurse at this time is to assess the client's spiritual beliefs.
Page Ref: 1969
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11) A pediatric nurse is caring for an 18-month-old infant. While making rounds the nurse enters
the room and finds the infant's father violently shaking the infant. The father attempts to make it
appear as though the infant was choking. Upon further assessment the nurse notes bruised areas
on the infant's arms and legs. What is a priority action for the nurse to take?
A) Discuss what she witnessed with the infant's mother.
B) Discuss what she witnessed with the other nurses.
C) Report what she witnessed and assessed to child protective services.
D) Report what she witnessed and assessed to the local law enforcement agency.
Answer: C
Explanation: A) Due to mandatory reporting laws, nurses must report all suspected cases of
child abuse to the appropriate child protective services agency. It would not be appropriate at this
time to discuss the findings with the infant's mother. The nurse does not know if the mother is
aware of what is occurring and it would be best to have this further investigated. It would not be
appropriate to discuss the findings with the other nurses as due to privacy regulations this
information would be shared on a need-to-know basis.
B) Due to mandatory reporting laws, nurses must report all suspected cases of child abuse to the
appropriate child protective services agency. It would not be appropriate at this time to discuss
the findings with the infant's mother. The nurse does not know if the mother is aware of what is
occurring and it would be best to have this further investigated. It would not be appropriate to
discuss the findings with the other nurses as due to privacy regulations this information would be
shared on a need-to-know basis.
C) Due to mandatory reporting laws, nurses must report all suspected cases of child abuse to the
D) Due to mandatory reporting laws, nurses must report all suspected cases of child abuse to the
Page Ref: 1974
24
Exemplar 32.2 Assault and Homicide
1) An adolescent client with fetal alcohol syndrome was arrested for assaulting another teenager
after being distracted and missing the school bus. The nurse realizes the client's outburst was
most likely due to:
A) Dislike of the other teenager.
B) Fetal alcohol syndrome.
C) Fetal alcohol syndrome and an environmental stressor.
D) Anger over being distracted.
Answer: C
Explanation: A) Early brain injury, as with prenatal alcohol exposure, is a risk factor in
aggression but is not enough by itself. When the injury is combined with other genetic factors
and environmental stressors, impulsiveness and aggression may be triggered. The client's
outburst was most likely due to the fetal alcohol syndrome and an environmental stressor. There
is not enough information to determine whether the client likes or dislikes the other teenager or if
the client was angry because he was distracted.
B) Early brain injury, as with prenatal alcohol exposure, is a risk factor in aggression but is not
enough by itself. When the injury is combined with other genetic factors and environmental
stressors, impulsiveness and aggression may be triggered. The client's outburst was most likely
due to the fetal alcohol syndrome and an environmental stressor. There is not enough
information to determine whether the client likes or dislikes the other teenager or if the client
was angry because he was distracted.
C) Early brain injury, as with prenatal alcohol exposure, is a risk factor in aggression but is not
D) Early brain injury, as with prenatal alcohol exposure, is a risk factor in aggression but is not
Page Ref: 1976
direct and indirect causes of assault and homicide.
25
2) A client was admitted with a gunshot wound sustained during a robbery. What does the nurse
suspect contributed to this client's injury?
A) The crime's suburban location
B) The gunman's unemployment
C) The gunman's age of 45
D) The gunman's college education
Answer: B
Explanation: A) Unemployment or other causes of social stress (e.g., homelessness, racial/ethnic
tension) are risk factors for social violence. Risk factors for committing other-directed violence
are the highest from ages 1 through 24 years. Poor socioeconomic background, urban location,
and lack of education are additional risk factors for violence.
B) Unemployment or other causes of social stress (e.g., homelessness, racial/ethnic tension) are
risk factors for social violence. Risk factors for committing other-directed violence are the
highest from ages 1 through 24 years. Poor socioeconomic background, urban location, and lack
of education are additional risk factors for violence.
C) Unemployment or other causes of social stress (e.g., homelessness, racial/ethnic tension) are
D) Unemployment or other causes of social stress (e.g., homelessness, racial/ethnic tension) are
Page Ref: 1977
Learning Outcome: 2. Identify risk factors and prevention methods associated with assault and
homicide.
26
3) A school-age client is admitted with dog bites and scratches obtained when throwing rocks at
a neighbor's dog. What should the nurse do to help this client?
A) Tell the client that he might go to jail for hurting the dog.
B) Ask the client where his parents were when he was hurting the dog.
C) Suggest to the client that it is not okay to harm animals.
D) Ask the client what he intended to accomplish by hurting the dog.
Answer: C
Explanation: A) When communicating with the school-age client who was hurting a dog, the
nurse should suggest that that it is not okay to harm animals. The nurse should not ask the client
what the intention was by hurting the dog or ask where his parents were when he was hurting the
dog. The nurse should not threaten the client with jail.
B) When communicating with the school-age client who was hurting a dog, the nurse should
suggest that that it is not okay to harm animals. The nurse should not ask the client what the
intention was by hurting the dog or ask where his parents were when he was hurting the dog. The
nurse should not threaten the client with jail.
C) When communicating with the school-age client who was hurting a dog, the nurse should
D) When communicating with the school-age client who was hurting a dog, the nurse should
Page Ref: 1375
the life span for individuals who have been assaulted.
27
4) Security was contacted to remove a handgun from the pants pocket of a client who had been
admitted with wounds sustained in a fight. Which diagnosis should the nurse include in this
client's care plan?
A) Risk for Violence to Others
B) Risk for Loneliness
C) Risk for Situational Low Self-Esteem
D) Fear
Answer: A
Explanation: A) The client had a handgun in a pants pocket that could have been used on others
in the client's environment. The diagnosis of Risk for Violence to Others is appropriate for this
client. There is not enough information to determine whether or not the client has a self-esteem
disturbance, is afraid, or is at risk for loneliness.
B) The client had a handgun in a pants pocket that could have been used on others in the client's
environment. The diagnosis of Risk for Violence to Others is appropriate for this client. There is
not enough information to determine whether or not the client has a self-esteem disturbance, is
afraid, or is at risk for loneliness.
C) The client had a handgun in a pants pocket that could have been used on others in the client's
D) The client had a handgun in a pants pocket that could have been used on others in the client's
Page Ref: 1981
has been assaulted.
28
5) The nurse is planning care for a client recovering from injuries sustained in a gang fight. What
should be included in this client's plan of care?
A) Need for adequate rest and physical activity
B) Methods to reduce anger other than force or physical violence
C) Employment counseling
D) Monitor intake and output
E) Setting limits
Answer: A, B, E
Explanation: A) The nurse should plan to provide methods to reduce anger other than force or
physical violence because the client is recovering from injuries sustained in a gang fight. The
nurse should also set limits with the client who has limited self-control. The client may or may
not need intake and output monitored; this will depend upon the injuries. The client may not be
old enough for employment counseling. Adequate rest and physical activity are important for all
clients.
B) The nurse should plan to provide methods to reduce anger other than force or physical
violence because the client is recovering from injuries sustained in a gang fight. The nurse
should also set limits with the client who has limited self-control. The client may or may not
need intake and output monitored; this will depend upon the injuries. The client may not be old
enough for employment counseling. Adequate rest and physical activity are important for all
clients.
C) The nurse should plan to provide methods to reduce anger other than force or physical
clients.
D) The nurse should plan to provide methods to reduce anger other than force or physical
clients.
E) The nurse should plan to provide methods to reduce anger other than force or physical
clients.
Page Ref: 1981
Learning Outcome: 5. Plan evidence-based care for an individual who has been assaulted and
his or her family in collaboration with other members of the healthcare team.
29
6) A client with a history of frequent outbursts and fighting has been receiving treatment to help
control emotions and anger. Which client statement shows that treatment has been effective?
A) "My brothers are the only ones I can fight with and not get in trouble."
B) "There are other ways to deal with anger, and I will use them instead of fighting."
C) "Hitting people is only justified sometimes."
D) "As long as my mother doesn't hit me first, I will not hit her."
Answer: B
Explanation: A) A client with a history of frequent outbursts and fighting would demonstrate
improvement with interventions by stating that the client will use other ways to deal with anger
instead of fighting. Hitting people is never justified. The client should not plan to fight with his
brothers. The client should not plan to hit his mother. These are evidence that interventions have
not been effective.
B) A client with a history of frequent outbursts and fighting would demonstrate improvement
with interventions by stating that the client will use other ways to deal with anger instead of
fighting. Hitting people is never justified. The client should not plan to fight with his brothers.
The client should not plan to hit his mother. These are evidence that interventions have not been
effective.
C) A client with a history of frequent outbursts and fighting would demonstrate improvement
effective.
D) A client with a history of frequent outbursts and fighting would demonstrate improvement
effective.
Page Ref: 1981
Learning Outcome: 6. Evaluate expected outcomes for an individual who has been assaulted.
30
7) The family of a victim of a gunshot wound is asking Emergency Department personnel if they
could find out the status of their family member. What should the nurse do to assist the client's
family?
A) Suggest they go to the cafeteria to get something to eat or drink.
B) Suggest they return home, and the hospital will phone them with any information.
C) Contact social services or the hospital chaplain to provide support while they wait.
D) Escort the family to see the client.
Answer: C
Explanation: A) The family is not receiving any information regarding the status of the client.
The nurse should ask social services or the hospital chaplain to provide support while the family
waits. The family should not be encouraged to go to the cafeteria or home. The client's status
may not be stable, and therefore the family should not be escorted to see the client.
B) The family is not receiving any information regarding the status of the client. The nurse
should ask social services or the hospital chaplain to provide support while the family waits. The
family should not be encouraged to go to the cafeteria or home. The client's status may not be
stable, and therefore the family should not be escorted to see the client.
C) The family is not receiving any information regarding the status of the client. The nurse
D) The family is not receiving any information regarding the status of the client. The nurse
Page Ref: 1981
care of an individual who has been assaulted.
31
8) What should the nurse do to assist a client brought to the Emergency Department as a victim
of a gunshot wound?
A) Ask the client who shot him.
B) Bathe the client and provide a clean gown.
C) Ask the client where the weapon is.
D) Preserve the chain of evidence.
Answer: D
Explanation: A) Because the majority of gunshot wounds require an investigation by law
enforcement, nurses working in emergency departments and trauma centers should be familiar
with their agency's protocols for maintaining evidence required by law enforcement. Often, law
enforcement does not want the victim's hands or the area around the victim's wounds cleansed.
Clothes and personal items are often wanted as evidence. The nurse should not bathe the client
and provide a clean gown. The nurse should not ask the client who shot him or where the
weapon is. The nurse should preserve the chain of evidence.
B) Because the majority of gunshot wounds require an investigation by law enforcement, nurses
working in emergency departments and trauma centers should be familiar with their agency's
protocols for maintaining evidence required by law enforcement. Often, law enforcement does
not want the victim's hands or the area around the victim's wounds cleansed. Clothes and
personal items are often wanted as evidence. The nurse should not bathe the client and provide a
clean gown. The nurse should not ask the client who shot him or where the weapon is. The nurse
should preserve the chain of evidence.
C) Because the majority of gunshot wounds require an investigation by law enforcement, nurses
D) Because the majority of gunshot wounds require an investigation by law enforcement, nurses
Page Ref: 1980
Learning Outcome: 6. Plan evidence-based care for an individual who has been assaulted and
32
9) What would the Emergency Department Nurse identify as clinical priorities for the treatment
of a client with a gunshot wound?
A) Airway maintenance
B) Obtaining medical history
C) Ventilation assistance
D) Hemorrhage control
E) Hypothermia prevention
Answer: A, C, D, E
Explanation: A) Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the client's neurologic status, as well as
prevention of infection. While obtaining the client's medical history is important, this action
would not be priority and would take place after the priority assessment and treatment. Once the
safety of the client is assured then the nurse will manage the client's emotional state and obtain
the medical history.
B) Clinical priorities for the treatment of gunshot wound are the following: maintain airway and
assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a
rapid, recurrent assessment of the client's neurologic status, as well as prevention of infection.
While obtaining the client's medical history is important, this action would not be priority and
would take place after the priority assessment and treatment. Once the safety of the client is
assured then the nurse will manage the client's emotional state and obtain the medical history.
C) Clinical priorities for the treatment of gunshot wound are the following: maintain airway and
D) Clinical priorities for the treatment of gunshot wound are the following: maintain airway and
E) Clinical priorities for the treatment of gunshot wound are the following: maintain airway and
Page Ref: 1981
the life span for individuals who have been assaulted.
33
10) A client is brought into the Emergency Department after being assaulted. It is suspected that
the client has a spinal cord injury. Which diagnostic test would be performed if this type of
injury were suspected?
A) Computed tomography (CT) scan
B) X-ray
C) Ultrasound
D) Magnetic resonance imaging (MRI)
Answer: D
Explanation: A) An MRI will be performed if there is a risk for spinal cord injuries, injuries to
the muscles, or abdominal injuries. A computed tomography (CT) scan is performed if internal
bleeding is suspected. An x-ray will be performed for potential broken or fractured bones. An
ultrasound is performed if internal bleeding is suspected.
B) An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or
abdominal injuries. A computed tomography (CT) scan is performed if internal bleeding is
suspected. An x-ray will be performed for potential broken or fractured bones. An ultrasound is
performed if internal bleeding is suspected.
C) An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or
D) An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or
Page Ref: 1979
care of an individual who has been assaulted.
34
11) A nursing instructor is educating a group of students on culture and diversity as it relates to
homicide. Which statement made by a student nurse would indicate to the instructor that further
education is needed?
A) "Caucasian individuals are more likely to use a gun as a means of homicide than any other
weapon."
B) "Stranger homicides typically are not interracial."
C) "The homicide rate among African American individuals is considerably higher than that
among individuals of other races."
D) "Caucasian individuals are significantly more likely to commit homicides involving multiple
victims."
Answer: A
Explanation: A) "Caucasian individuals are more like to use a gun ..." is incorrect and indicates
the need for further instruction. The other statements are correct.
B) "Caucasian individuals are more like to use a gun ..." is incorrect and indicates the need for
further instruction. The other statements are correct.
C) "Caucasian individuals are more like to use a gun ..." is incorrect and indicates the need for
D) "Caucasian individuals are more like to use a gun ..." is incorrect and indicates the need for
Page Ref: 1979
Learning Outcome: 2. Identify risk factors and prevention methods associated with assault and
homicide.
35
Exemplar 32.3 Rape and Rape-Trauma Syndrome
1) The nurse is caring for a client who was raped. What does the nurse understand as the
underlying issue of most rapists?
A) A desire to overpower and control
B) A desire to play out fantasies
C) An uncontrollably strong sex drive
D) The inability to control intense anxiety
E) Acting out aggression
Answer: A, E
Explanation: A) Rape is a crime of violence generated by issues of power and anger and the
acting out of aggression rather than by sex drive, fantasies, or the inability to control anxiety.
B) Rape is a crime of violence generated by issues of power and anger and the acting out of
aggression rather than by sex drive, fantasies, or the inability to control anxiety.
C) Rape is a crime of violence generated by issues of power and anger and the acting out of
D) Rape is a crime of violence generated by issues of power and anger and the acting out of
E) Rape is a crime of violence generated by issues of power and anger and the acting out of
Page Ref: 1984
direct and indirect causes of rape and rape-trauma syndrome.
36
2) The nurse determines that a client is at risk for being raped when which characteristic or
characteristics are assessed?
A) Previous history of being raped
B) Current substance abuse
C) Lives with parents
D) Attends community college
E) Unemployed
Answer: A, B, E
Explanation: A) Risk factors for rape include drug use, having been previously raped, and
poverty. Living with parents and attending college are not specific risk factors for rape.
B) Risk factors for rape include drug use, having been previously raped, and poverty. Living
with parents and attending college are not specific risk factors for rape.
C) Risk factors for rape include drug use, having been previously raped, and poverty. Living
D) Risk factors for rape include drug use, having been previously raped, and poverty. Living
E) Risk factors for rape include drug use, having been previously raped, and poverty. Living with
parents and attending college are not specific risk factors for rape.
Page Ref: 1984-1985
37
3) The nurse is caring for a victim of rape. What are the priorities of care for this client?
A) Notifying an attorney for the client
B) Supporting the victim during the examination
C) Identifying the individual who committed the rape
D) Treating acute injuries
E) Providing referrals for follow-up care
Answer: B, D, E
Explanation: A) Priorities of nursing care include treating any acute injuries, supporting the
victim during the examination, and providing referrals for follow-up care. Nursing priorities do
not include identifying the individual who committed the rape or notifying an attorney for the
client.
B) Priorities of nursing care include treating any acute injuries, supporting the victim during the
examination, and providing referrals for follow-up care. Nursing priorities do not include
identifying the individual who committed the rape or notifying an attorney for the client.
C) Priorities of nursing care include treating any acute injuries, supporting the victim during the
D) Priorities of nursing care include treating any acute injuries, supporting the victim during the
E) Priorities of nursing care include treating any acute injuries, supporting the victim during the
Page Ref: 1988
the life span for individuals who have been raped.
38
4) A client who was raped refuses to see any male physicians, tells the nurse that she had an
"incident" that she does not want to talk about, and wants a bed by the door. The nurse identifies
which diagnosis as being appropriate for the client at this time?
A) Relocation Stress Syndrome
B) Readiness for Enhanced Power
C) Rape-Trauma Syndrome
D) Acute Confusion
Answer: C
Explanation: A) The nursing diagnosis of Rape-Trauma Syndrome applies if the client
experiences high levels of anxiety, an inability to discuss the trauma, abrupt changes in
relationships with men or changes in sexual behavior, and the onset of phobic reactions. This
client is not displaying evidence of readiness for enhanced power. There is no evidence that the
client is experiencing relocation stress syndrome or acute confusion.
B) The nursing diagnosis of Rape-Trauma Syndrome applies if the client experiences high levels
of anxiety, an inability to discuss the trauma, abrupt changes in relationships with men or
changes in sexual behavior, and the onset of phobic reactions. This client is not displaying
evidence of readiness for enhanced power. There is no evidence that the client is experiencing
relocation stress syndrome or acute confusion.
C) The nursing diagnosis of Rape-Trauma Syndrome applies if the client experiences high levels
D) The nursing diagnosis of Rape-Trauma Syndrome applies if the client experiences high levels
Page Ref: 1988
has been raped.
39
5) Which of the following are appropriate ongoing, long-term treatment goals for a victim who
experienced sexual abuse 8 months ago?
A) Demonstrate effective coping strategies.
B) Involve significant others in the treatment plan.
C) Become aware of legal rights.
D) Establish rapport and build a trusting nurse-client relationship.
E) Move from victim to survivor status.
Answer: A, E
Explanation: A) The process of moving a client from victim to survivor status and
demonstrating effective coping strategies may take months to years, whereas the other treatment
goals can be met in the short term (hours to days). The nurse should have involved significant
others in the treatment plan, established rapport, and made the client aware of legal rights
immediately after the sexual abuse occurred.
B) The process of moving a client from victim to survivor status and demonstrating effective
coping strategies may take months to years, whereas the other treatment goals can be met in the
short term (hours to days). The nurse should have involved significant others in the treatment
plan, established rapport, and made the client aware of legal rights immediately after the sexual
abuse occurred.
C) The process of moving a client from victim to survivor status and demonstrating effective
abuse occurred.
D) The process of moving a client from victim to survivor status and demonstrating effective
abuse occurred.
E) The process of moving a client from victim to survivor status and demonstrating effective
abuse occurred.
Page Ref: 1988
Learning Outcome: 5. Plan evidence-based care for an individual who has been raped and his or
her family in collaboration with other members of the healthcare team.
40
6) A client recovering from a rape tells the nurse that flashbacks do occur but can be managed.
Which technique(s) could the client be using to manage flashbacks about the event?
A) Restoring personal choice
B) Deep breathing
C) Muscle relaxation
D) Problem solving
E) Guided imagery
Answer: B, C, E
Explanation: A) Techniques that the client can use to control flashbacks include muscle
relaxation, deep breathing, and guided imagery. Problem solving and restoring personal choice
are techniques to support coping behaviors.
B) Techniques that the client can use to control flashbacks include muscle relaxation, deep
breathing, and guided imagery. Problem solving and restoring personal choice are techniques to
support coping behaviors.
C) Techniques that the client can use to control flashbacks include muscle relaxation, deep
D) Techniques that the client can use to control flashbacks include muscle relaxation, deep
E) Techniques that the client can use to control flashbacks include muscle relaxation, deep
Page Ref: 1988
care of an individual who has been raped.
41
7) A client who was raped tells the nurse that she must not get pregnant. What would be an
appropriate response by the nurse?
A) "The baby could always be given up for adoption."
B) "You will not know for sure for at least a few more days."
C) "There is a medication called Plan B, which is emergency contraception."
D) "Are you sure the rapist did not use a condom?"
Answer: C
Explanation: A) Female rape victims may request information about emergency contraception if
the attacker did not use a condom. Plan B (levonorgestrel) is available over the counter and may
be made available to the client at the facility performing the examination following the attack.
The nurse should discuss the medication Plan B with the client. The nurse should not tell the
client that it will be a few more days to know for sure if she is pregnant. The nurse should not
question whether the rapist used a condom. The client does not want to get pregnant. The nurse
should not talk about giving a baby up for adoption at this time.
B) Female rape victims may request information about emergency contraception if the attacker
did not use a condom. Plan B (levonorgestrel) is available over the counter and may be made
available to the client at the facility performing the examination following the attack. The nurse
should discuss the medication Plan B with the client. The nurse should not tell the client that it
will be a few more days to know for sure if she is pregnant. The nurse should not question
whether the rapist used a condom. The client does not want to get pregnant. The nurse should not
talk about giving a baby up for adoption at this time.
C) Female rape victims may request information about emergency contraception if the attacker
D) Female rape victims may request information about emergency contraception if the attacker
Page Ref: 1988
Learning Outcome: 5. Plan evidence-based care for an individual who has been raped and his or
her family in collaboration with other members of the healthcare team.
42
8) What can the nurse do to assist a client who was raped identify and prioritize concerns?
A) Help the client use problem-solving skills.
B) Provide anti-anxiety medication.
C) Tell the client that the event is over and it is now time to move on.
D) Instruct in guided imagery.
Answer: A
Explanation: A) When helping the client who is victim of a rape with identifying and
prioritizing concerns, the nurse should help the client use the problem-solving process. Guided
imagery will help with flashbacks. Antianxiety medication will not help the client prioritize
concerns. The nurse should not tell the client to "move on." Only the client knows when she will
be ready to do this.
B) When helping the client who is victim of a rape with identifying and prioritizing concerns, the
nurse should help the client use the problem-solving process. Guided imagery will help with
flashbacks. Antianxiety medication will not help the client prioritize concerns. The nurse should
not tell the client to "move on." Only the client knows when she will be ready to do this.
C) When helping the client who is victim of a rape with identifying and prioritizing concerns, the
D) When helping the client who is victim of a rape with identifying and prioritizing concerns, the
Page Ref: 1988
Learning Outcome: 6. Evaluate expected outcomes for an individual who has been raped.
43
9) The nurse working in the Emergency Department is aware that rape victims initially exhibit
which emotions?
A) Shock
B) Disbelief
C) Anger
D) Self-blame
E) Denial
Answer: A, B, E
Explanation: A) Initial responses to rape generally include feelings of shock, denial, and
disbelief. Anger and self-blame are early responses but not typically the initial response.
B) Initial responses to rape generally include feelings of shock, denial, and disbelief. Anger and
self-blame are early responses but not typically the initial response.
C) Initial responses to rape generally include feelings of shock, denial, and disbelief. Anger and
D) Initial responses to rape generally include feelings of shock, denial, and disbelief. Anger and
E) Initial responses to rape generally include feelings of shock, denial, and disbelief. Anger and
Page Ref: 1985
44
10) A rape victim is being seen in the clinic. Upon assessment it is discovered the client has
contracted syphilis. The clinic nurse would anticipate which pharmacological treatment will be
prescribed?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Tinidazole
D) Doxycycline
Answer: A
Explanation: A) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of
ceftriaxone and either azithromycin or doxycycline. Trichomoniasis is treated with tinidazole or
metronidazole. Chlamydia is treated with doxycycline.
B) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and
either azithromycin or doxycycline. Trichomoniasis is treated with tinidazole or metronidazole.
Chlamydia is treated with doxycycline.
C) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and
D) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and
Page Ref: 1987
Client Need Sub: Pharmacological and Parenteral Therapies
45
11) A rape victim is being seen in the clinic. Upon assessment it is discovered the client has
contracted trichomoniasis. The clinic nurse would anticipate which pharmacological treatment
will be prescribed?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Metronidazole
D) Doxycycline
Answer: C
Explanation: A) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated
with penicillin. Gonorrhea is treated with a combination of ceftriaxone and either azithromycin
or doxycycline. Chlamydia is treated with doxycycline.
B) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin.
Gonorrhea is treated with a combination of ceftriaxone and either azithromycin or doxycycline.
C) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin.
D) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin.
Page Ref: 1987
46
Exemplar 32.4 Suicide
1) A client often asks what life would be like if he had never been born or if he were to die. What
does the nurse suspect this client is at risk for?
A) A suicide attempt
B) Suicide planning
C) A suicide threat
D) Suicidal ideation
Answer: D
Explanation: A) Suicidal ideation is having thoughts of harming or killing oneself. A suicide is
more serious than a casual statement of suicidal intent and is accompanied by other behavior
changes, including mood swings, temper outbursts, a decline in school or work performance,
personality changes, sudden or gradual withdrawal from friends, and other significant changes in
attitude. A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or inferred
intent to die. The attempt may be thwarted by another individual or by circumstances, it may be
planned to avoid serious injury, or it may be one in which the outcome depends on the
circumstances and is not under the individual's control. A suicide plan is a decision to commit
suicide and an identified method.
B) Suicidal ideation is having thoughts of harming or killing oneself. A suicide is more serious
than a casual statement of suicidal intent and is accompanied by other behavior changes,
including mood swings, temper outbursts, a decline in school or work performance, personality
changes, sudden or gradual withdrawal from friends, and other significant changes in attitude. A
suicide attempt is a nonfatal, self-inflicted destructive act with explicit or inferred intent to die.
The attempt may be thwarted by another individual or by circumstances, it may be planned to
avoid serious injury, or it may be one in which the outcome depends on the circumstances and is
not under the individual's control. A suicide plan is a decision to commit suicide and an
identified method.
C) Suicidal ideation is having thoughts of harming or killing oneself. A suicide is more serious
identified method.
47
D) Suicidal ideation is having thoughts of harming or killing oneself. A suicide is more serious
identified method.
Page Ref: 1990
direct and indirect causes of suicide.
48
2) Which assessment finding or findings increase a client's risk for suicidal ideation or behavior?
A) Substance abuse
B) Age 59
C) Plays golf twice a week
D) Widowed for 6 months
E) Recently started a new job
Answer: A, D
Explanation: A) Of the assessment findings, the ones that would increase the client's risk for
suicidal ideation or behavior are the recent loss of a spouse and substance abuse. For the risk of
age, elderly male clients have the highest risk followed by adolescents and college students.
Active employment and engagement in activities do not increase the risk for suicidal ideation or
behavior.
B) Of the assessment findings, the ones that would increase the client's risk for suicidal ideation
or behavior are the recent loss of a spouse and substance abuse. For the risk of age, elderly male
clients have the highest risk followed by adolescents and college students. Active employment
and engagement in activities do not increase the risk for suicidal ideation or behavior.
C) Of the assessment findings, the ones that would increase the client's risk for suicidal ideation
D) Of the assessment findings, the ones that would increase the client's risk for suicidal ideation
E) Of the assessment findings, the ones that would increase the client's risk for suicidal ideation
Page Ref: 1992
Learning Outcome: 2. Identify risk factors and prevention methods associated with suicide.
49
3) An adolescent client hospitalized with asphyxiation from a failed suicide attempt tells the
nurse, "I know other kids have the same problems I do, but I just wanted to make it stop." What
should the nurse do to help this client?
A) Discuss the client's attendance at school and what activities are enjoyed.
B) Suggest the client listen to music and read a light novel to reduce stress.
C) Ask if the client would like to talk about stressors and problems.
D) Ask what is so devastating that the client needed to commit suicide.
Answer: C
Explanation: A) Those who attempt suicide are overcome by and overwhelmed with stressors in
their lives. The nurse should ask the client to talk about her stressors and problems. The nurse
should not ask the client about what caused the attempt at suicide. The nurse should also not try
to distract the client by asking about school and activities. Suggesting the client read and listen to
music may not be sufficient to reduce the client's stress.
B) Those who attempt suicide are overcome by and overwhelmed with stressors in their lives.
The nurse should ask the client to talk about her stressors and problems. The nurse should not
ask the client about what caused the attempt at suicide. The nurse should also not try to distract
the client by asking about school and activities. Suggesting the client read and listen to music
may not be sufficient to reduce the client's stress.
C) Those who attempt suicide are overcome by and overwhelmed with stressors in their lives.
D) Those who attempt suicide are overcome by and overwhelmed with stressors in their lives.
Page Ref: 1993
the life span for individuals who have attempted suicide.
50
4) The parents of a client who committed suicide are observed arguing in the Emergency
Department waiting area. What does the nurse realize the parents are at risk for developing?
A) Risk for violence
B) Ineffective family coping
C) Anxiety
D) Situational low self-esteem
Answer: B
Explanation: A) Because the client committed suicide, the parents of the client become the
nurse's clients. The parents are observed arguing in the waiting room, which would indicate
ineffective family coping. There is no way to determine if the parents are experiencing
situational low self-esteem. The parents are probably experiencing anxiety; however, ineffective
family coping is the priority. There is no way of knowing if the parents are at risk for violence.
B) Because the client committed suicide, the parents of the client become the nurse's clients. The
parents are observed arguing in the waiting room, which would indicate ineffective family
coping. There is no way to determine if the parents are experiencing situational low self-esteem.
The parents are probably experiencing anxiety; however, ineffective family coping is the
priority. There is no way of knowing if the parents are at risk for violence.
C) Because the client committed suicide, the parents of the client become the nurse's clients. The
D) Because the client committed suicide, the parents of the client become the nurse's clients. The
Page Ref: 1990
has attempted suicide.
51
5) The nurse is planning care for a client to prevent future suicidal behavior. Which interaction(s)
would be appropriate for this client?
A) Add the names of community resources to a crisis card.
B) Assist in creating a crisis card listing family members.
C) Focus on reasons for living.
D) Limit exposure to friends.
E) Identify self-directed harmful behaviors.
Answer: A, B
Explanation: A) To help prevent future suicidal behavior, the nurse should assist the client to
develop a crisis card that lists the names, addresses, and telephone numbers of family members
and the names and telephone numbers of community resource crisis centers. Identifying self-
directed harmful behaviors will not prevent future suicidal behavior. Limiting exposure to
friends will not prevent future suicidal behavior. Focusing on reasons for living is an intervention
to promote problem solving.
B) To help prevent future suicidal behavior, the nurse should assist the client to develop a crisis
card that lists the names, addresses, and telephone numbers of family members and the names
and telephone numbers of community resource crisis centers. Identifying self-directed harmful
behaviors will not prevent future suicidal behavior. Limiting exposure to friends will not prevent
future suicidal behavior. Focusing on reasons for living is an intervention to promote problem
solving.
C) To help prevent future suicidal behavior, the nurse should assist the client to develop a crisis
solving.
D) To help prevent future suicidal behavior, the nurse should assist the client to develop a crisis
solving.
E) To help prevent future suicidal behavior, the nurse should assist the client to develop a crisis
solving.
Page Ref: 1996
Learning Outcome: 6. Plan evidence-based care for an individual who has attempted suicide and
52
6) The nurse caring for a client recovering from a suicide attempt determines that care has been
beneficial to eliminate future suicide attempts when the client states:
A) "I am not looking forward to going home with my parents."
B) "I now know that threatening suicide will help me get what I want from my parents."
C) "Even though I failed this time, I lived to think about it again."
D) "I am looking forward to going to school and seeing my friends."
Answer: D
Explanation: A) The statement "I am looking forward to going to school and seeing my friends"
indicates hope for the future, which is a desired outcome of care for a client who is at risk for
suicide. The other statements indicate that the client may need further intervention either before
discharge or once at home.
B) The statement "I am looking forward to going to school and seeing my friends" indicates hope
for the future, which is a desired outcome of care for a client who is at risk for suicide. The other
statements indicate that the client may need further intervention either before discharge or once
at home.
C) The statement "I am looking forward to going to school and seeing my friends" indicates hope
for the future, which is a desired outcome of care for a client who is at risk for suicide. The other
statements indicate that the client may need further intervention either before discharge or once
at home.
D) The statement "I am looking forward to going to school and seeing my friends" indicates
hope for the future, which is a desired outcome of care for a client who is at risk for suicide. The
other statements indicate that the client may need further intervention either before discharge or
once at home.
Page Ref: 1996
Learning Outcome: 7. Evaluate expected outcomes for an individual who has attempted suicide.
53
7) A client who has attempted to commit suicide in the past tells the nurse about feeling better
since being prescribed an antidepressant medication. The nurse realizes the medication has done
what for the client?
A) Improved mood
B) Improved sleep
C) Improved feelings of guilt
D) Improved appetite
Answer: A
Explanation: A) Antidepressants treat major depression by enhancing mood. Antidepressants are
also prescribed to treat anxiety disorders. Recent studies link depression and anxiety to similar
neurotransmitter dysfunction, and both seem to respond to treatment with antidepressant
medications. An improvement in appetite and sleep might occur with antidepressant medication;
however, the medication does not directly stimulate the appetite or cause sleep. Antidepressant
medication is not known to improve feelings of guilt.
B) Antidepressants treat major depression by enhancing mood. Antidepressants are also
prescribed to treat anxiety disorders. Recent studies link depression and anxiety to similar
C) Antidepressants treat major depression by enhancing mood. Antidepressants are also
D) Antidepressants treat major depression by enhancing mood. Antidepressants are also
Page Ref: 1995
care of an individual who has attempted suicide.
54
8) The nurse is working with a client to create a crisis care card in the event the client wants to
attempt suicide in the future. What should be included on this card?
A) Name of client's physician
B) Name of client
C) Address of client
D) Name and address of friends to call in case of a crisis
Answer: D
Explanation: A) Elements of a crisis care card include names and phone numbers of competent
and willing family and friends; numbers of community resources, such as hotlines, mental health
emergency centers, and local Emergency Departments; reasonable, non-suicidal responses to
problems; and a list of activities that have helped in the past. The client's name, address, and
physician are not usually a part of the crisis care card.
B) Elements of a crisis care card include names and phone numbers of competent and willing
family and friends; numbers of community resources, such as hotlines, mental health emergency
centers, and local Emergency Departments; reasonable, non-suicidal responses to problems; and
a list of activities that have helped in the past. The client's name, address, and physician are not
usually a part of the crisis care card.
C) Elements of a crisis care card include names and phone numbers of competent and willing
D) Elements of a crisis care card include names and phone numbers of competent and willing
Page Ref: 1996
Learning Outcome: 6. Plan evidence-based care for an individual who has attempted suicide and
55
9) A nurse is conducting an admission assessment on a client admitted for thoughts of suicide.
The nurse is determining the client's risk for suicide. Which would indicate to the nurse that the
client is at a low level risk of suicide?
A) Displays mild depression.
B) Shows curiosity about death.
C) Discusses taking his or her life.
D) Admits planning to end his or her life.
E) Discusses a plan to end his or her life in detail.
Answer: A, B
Explanation: A) Displaying mild depression and showing curiosity about death indicate low-
level risk for suicide. Discussing taking his or her life, planning to end life, and discussing such
plans in detail indicate high-level risk of suicide.
B) Displaying mild depression and showing curiosity about death indicate low-level risk for
suicide. Discussing taking his or her life, planning to end life, and discussing such plans in detail
indicate high-level risk of suicide.
C) Displaying mild depression and showing curiosity about death indicate low-level risk for
D) Displaying mild depression and showing curiosity about death indicate low-level risk for
E) Displaying mild depression and showing curiosity about death indicate low-level risk for
Page Ref: 1995-1996
56
10) A nurse is interviewing a client with a recent suicide attempt. What would be an appropriate
question for the nurse to ask?
A) "Do you currently have a plan for killing yourself?"
B) "Why would you think about hurting yourself?"
C) "Have you thought about hurting yourself?"
D) "Do you ever think about hurting yourself?"
Answer: A
Explanation: A) It is helpful to recognize the client's current state by talking about depression
and asking direct questions such as "Do you currently have a plan for killing yourself?" This is
an effective type of questioning. The other questions are indirect and avoid the reality of the
situation and are, therefore, inappropriate.
B) It is helpful to recognize the client's current state by talking about depression and asking
direct questions such as "Do you currently have a plan for killing yourself?" This is an effective
type of questioning. The other questions are indirect and avoid the reality of the situation and are,
therefore, inappropriate.
C) It is helpful to recognize the client's current state by talking about depression and asking
D) It is helpful to recognize the client's current state by talking about depression and asking
Page Ref: 1996
Nursing Process: Communication
57
11) A nursing instructor is evaluating a nursing student's knowledge regarding a client with
suicidal thoughts. Which statement made by the student demonstrates an understanding
regarding assessing a client with suicidal thoughts?
A) "I should attempt to make light of the circumstances."
B) "I should be indirect and respectful."
C) "I should not talk about suicide directly."
D) "I should directly acknowledge the situation."
Answer: D
Explanation: A) Individuals who are experiencing suicidal ideation will respect direct
acknowledgment of the situation as opposed to a restrained approach. Nurses recognize the
severity and finality of the client's decision, and do not attempt to make light of the
circumstances. Nurses working with clients who are considering suicide, or who have recently
attempted suicide, should be direct but respectful when evaluating the client and asking
questions. It is a common misconception that talking about suicide directly could cause the client
to act in a suicidal manner, but this is not true.
B) Individuals who are experiencing suicidal ideation will respect direct acknowledgment of the
situation as opposed to a restrained approach. Nurses recognize the severity and finality of the
client's decision, and do not attempt to make light of the circumstances. Nurses working with
clients who are considering suicide, or who have recently attempted suicide, should be direct but
respectful when evaluating the client and asking questions. It is a common misconception that
talking about suicide directly could cause the client to act in a suicidal manner, but this is not
true.
C) Individuals who are experiencing suicidal ideation will respect direct acknowledgment of the
true.
D) Individuals who are experiencing suicidal ideation will respect direct acknowledgment of the
true.
Page Ref: 1995-1996
Nursing Process: Communication
58
Exemplar 32.5 Unintentional Injury: Motor Vehicle Crashes
1) A client recovering from a motor vehicle crash develops hypotension and severe jugular
distension with a tracheal deviation. What does the nurse suspect has occurred?
A) Hemorrhage
B) Compensatory shock
C) Hypovolemic shock
D) Tension pneumothorax
Answer: D
Explanation: A) A tension pneumothorax is life threatening and requires immediate
intervention. On inspiration, air enters the pleural space, does not escape on expiration, and
increases the intrapleural pressure. This pressure collapses the injured lung and shifts the
mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured
lung. Tracheal deviation and jugular vein distention are not associated with hemorrhage,
compensatory shock, or hypovolemic shock.
B) A tension pneumothorax is life threatening and requires immediate intervention. On
inspiration, air enters the pleural space, does not escape on expiration, and increases the
intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents,
compressing the heart, great vessels, trachea, and eventually the uninjured lung. Tracheal
deviation and jugular vein distention are not associated with hemorrhage, compensatory shock,
or hypovolemic shock.
C) A tension pneumothorax is life threatening and requires immediate intervention. On
D) A tension pneumothorax is life threatening and requires immediate intervention. On
Page Ref: 1998
direct and indirect causes of motor vehicle crashes.
59
2) A 72-year-old male is transported to the Emergency Department after a motor vehicle crash.
Which risk factor(s) are most common for this age group?
A) Unsafe driving practices
B) Preexisting health condition
C) Speeding
D) Texting
E) Reduced sensory perception
Answer: B, E
Explanation: A) Older adults are at risk of motor vehicle accidents due to preexisting health
conditions and decreased sensory perceptions. Younger adults are at risk of motor vehicle
accidents due to unsafe driving practices, speeding, and texting or other distractions.
B) Older adults are at risk of motor vehicle accidents due to preexisting health conditions and
decreased sensory perceptions. Younger adults are at risk of motor vehicle accidents due to
unsafe driving practices, speeding, and texting or other distractions.
C) Older adults are at risk of motor vehicle accidents due to preexisting health conditions and
D) Older adults are at risk of motor vehicle accidents due to preexisting health conditions and
E) Older adults are at risk of motor vehicle accidents due to preexisting health conditions and
Page Ref: 1999
Learning Outcome: 2. Identify risk factors and prevention methods associated with motor
vehicle crashes.
60
3) An older client is admitted with fractured femurs sustained in a motor vehicle crash. Once the
client is stabilized, what should the nurse assess in this client?
A) Blood pressure
B) Need for assistance once discharged to home
C) Car insurance carrier
D) The client's accident history
Answer: D
Explanation: A) The client is older and has sustained severe injuries from a motor vehicle
accident. This is a leading cause of death of older clients in the United States. The nurse needs to
find out if this is the client's first motor vehicle accident because the client might need to
relinquish his driver's license after a medical review of driving privileges. The nurse should
assess the client's blood pressure and need for assistance once discharged to home; however,
these interventions are not a priority. The nurse does not need to know the car insurance carrier.
B) The client is older and has sustained severe injuries from a motor vehicle accident. This is a
leading cause of death of older clients in the United States. The nurse needs to find out if this is
the client's first motor vehicle accident because the client might need to relinquish his driver's
license after a medical review of driving privileges. The nurse should assess the client's blood
pressure and need for assistance once discharged to home; however, these interventions are not a
priority. The nurse does not need to know the car insurance carrier.
C) The client is older and has sustained severe injuries from a motor vehicle accident. This is a
D) The client is older and has sustained severe injuries from a motor vehicle accident. This is a
Page Ref: 1999
the life span for individuals who have been involved in a motor vehicle crashes.
61
4) A client admitted with injuries from a motor vehicle crash tells the nurse that she sees the
truck coming at her every time she closes her eyes to sleep. What would be a priority nursing
diagnosis for this client?
A) Post-Trauma Syndrome
B) Risk for Infection
C) Ineffective Coping
D) Anxiety
Answer: A
Explanation: A) The client is reliving the motor vehicle accident every time she closes her eyes.
This indicates that the client is at risk for or has developed post-trauma syndrome. There is not
enough information to determine whether the client is at risk for infection, ineffective coping, or
anxiety.
B) The client is reliving the motor vehicle accident every time she closes her eyes. This indicates
that the client is at risk for or has developed post-trauma syndrome. There is not enough
information to determine whether the client is at risk for infection, ineffective coping, or anxiety.
C) The client is reliving the motor vehicle accident every time she closes her eyes. This indicates
D) The client is reliving the motor vehicle accident every time she closes her eyes. This indicates
Page Ref: 2003
has been involved in a motor vehicle crash.
62
5) The nurse is planning care for a client with multiple lower extremity fractures sustained from
a motor vehicle crash. What should the nurse include as a goal of care for this client?
A) Have an adequate urine output.
B) Regain mobility.
C) Participate in self-care activities.
D) Discharge to home.
Answer: B
Explanation: A) The client has sustained multiple lower extremity fractures. A goal of care for
this client is for the client to regain mobility. An adequate urine output is important, but healing
the client's fractures needs to be a goal of care. Participating in self-care activities and being
discharged to home are also important; however, because the client sustained multiple fractures
to the lower extremities, one goal of care must be focused on the client regaining mobility.
B) The client has sustained multiple lower extremity fractures. A goal of care for this client is for
the client to regain mobility. An adequate urine output is important, but healing the client's
fractures needs to be a goal of care. Participating in self-care activities and being discharged to
home are also important; however, because the client sustained multiple fractures to the lower
extremities, one goal of care must be focused on the client regaining mobility.
C) The client has sustained multiple lower extremity fractures. A goal of care for this client is for
D) The client has sustained multiple lower extremity fractures. A goal of care for this client is for
Page Ref: 2004-2005
Learning Outcome: 7. Plan evidence-based care for an individual who has been in a motor
vehicle crash and his or her family in collaboration with other members of the healthcare team.
63
6) Which observation indicates that interventions provided to a client with neck injuries from a
motor vehicle crash have been successful?
A) Urine is clear and odorless from indwelling catheter.
B) Moves all four extremities independently, feeds self, and participates in partial bath
C) Unable to move independently in bed
D) Rests in bed with lights and television turned off
Answer: B
Explanation: A) The client sustained neck injuries from a motor vehicle accident. With these
types of injuries, there is a risk for paralysis. Evidence that interventions have been successful
for this client includes moving all four extremities independently, feeding self, and participating
in partial bath care. This means the client has mobility, which is a successful outcome. The other
observations indicate that the client is not yet recovered from the injuries or that interventions for
the injuries have not yet been successful. The client who is in bed with the lights and television
turned off might need additional psychosocial support.
B) The client sustained neck injuries from a motor vehicle accident. With these types of injuries,
there is a risk for paralysis. Evidence that interventions have been successful for this client
includes moving all four extremities independently, feeding self, and participating in partial bath
care. This means the client has mobility, which is a successful outcome. The other observations
indicate that the client is not yet recovered from the injuries or that interventions for the injuries
have not yet been successful. The client who is in bed with the lights and television turned off
might need additional psychosocial support.
C) The client sustained neck injuries from a motor vehicle accident. With these types of injuries,
D) The client sustained neck injuries from a motor vehicle accident. With these types of injuries,
Page Ref: 2005
Learning Outcome: 7. Evaluate expected outcomes for an individual who has been in a motor
vehicle crash.
64
7) A client admitted for injuries sustained in a motor vehicle crash tells the nurse that he was hurt
much worse the last time he crashed. Which should the nurse do to assist this client?
A) Report the client to the department of motor vehicles.
B) Find out what caused today's car accident.
C) Ask if he enjoys crashing his cars.
D) Suggest attending a driver's safety course to learn how to avoid crashes.
Answer: D
Explanation: A) The client is a repeat offender with motor vehicle accidents and would most
likely benefit from a driver's safety course. This is what the nurse should suggest to the client.
The nurse should not ask the client if he enjoys crashing cars or ask why he had an accident
today. The nurse should not report the client to the department of motor vehicles.
B) The client is a repeat offender with motor vehicle accidents and would most likely benefit
from a driver's safety course. This is what the nurse should suggest to the client. The nurse
should not ask the client if he enjoys crashing cars or ask why he had an accident today. The
nurse should not report the client to the department of motor vehicles.
C) The client is a repeat offender with motor vehicle accidents and would most likely benefit
D) The client is a repeat offender with motor vehicle accidents and would most likely benefit
Page Ref: 1999
the life span for individuals who have been involved in motor vehicle crashes.
65
8) Which intervention would be a priority when providing care to a client recovering from
thoracic injuries sustained from a motor vehicle crash?
A) Monitor urine output.
B) Assess vital signs.
C) Perform passive range of motion to all extremities.
D) Assist to deep breath and cough every 2 hours.
Answer: D
Explanation: A) The client has thoracic injuries and might be reluctant to deep breathe and
cough because of pain. The nurse needs to ensure that the client breathes deeply and coughs
every 2 hours to mobilize secretions and prevent respiratory complications. Monitoring urine
output and assessing vital signs are important but not the priority at this time. The client may be
able to perform active range of motion for all extremities, so this intervention may or may not be
indicated.
B) The client has thoracic injuries and might be reluctant to deep breathe and cough because of
pain. The nurse needs to ensure that the client breathes deeply and coughs every 2 hours to
mobilize secretions and prevent respiratory complications. Monitoring urine output and assessing
vital signs are important but not the priority at this time. The client may be able to perform active
range of motion for all extremities, so this intervention may or may not be indicated.
C) The client has thoracic injuries and might be reluctant to deep breathe and cough because of
D) The client has thoracic injuries and might be reluctant to deep breathe and cough because of
Page Ref: 2004
care of an individual who has been in a motor vehicle crash.
66
9) A client presents to the Emergency Department with an incomplete spinal cord injury. The
nurse providing care to this client would anticipate which medication would be ordered to
decrease inflammation and nerve damage?
A) Hydrocodone (Vicodin)
B) Ibuprofen (Motrin)
C) Methylprednisolone (Medrol)
D) Xylocaine (Lidocaine)
Answer: C
Explanation: A) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to
decrease inflammation and prevent nerve damage. Hydrocodone (Vicodin) is a pain relief
medication. Ibuprofen (Motrin) is an anti-inflammatory given to clients to reduce swelling, such
as joint swelling. Xylocaine (Lidocaine) is injected into the affected muscle to relieve pain and
muscle spasms, such as muscle spasms related to whiplash.
B) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease
inflammation and prevent nerve damage. Hydrocodone (Vicodin) is a pain relief medication.
Ibuprofen (Motrin) is an anti-inflammatory given to clients to reduce swelling, such as joint
swelling. Xylocaine (Lidocaine) is injected into the affected muscle to relieve pain and muscle
spasms, such as muscle spasms related to whiplash.
C) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease
D) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease
Page Ref: 2002
care of an individual who has been in a motor vehicle crash.
67
10) The nurse at a local hospital is conducting a safety workshop for expecting parents
addressing newborn injury prevention and car seat safety. Which statement made by a parent
indicates a need for further teaching?
A) "My newborn should be in a car safety seat every time he is in the car."
B) "It is good if I place a blanket over the baby and then buckle the baby onto the seat."
C) "My newborn should ride rear-facing until at least 1 year of age and more than 20 pounds."
D) "Never place a rear-facing car safety seat in the front seat with an active passenger air bag."
Answer: B
Explanation: A) Never place blankets under the baby or under the belts. Buckle the baby into the
seat, and place blankets over the baby. Therefore this is an incorrect statement and indicates a
need for further instruction. The other statements are correct and indicate no need for further
education.
B) Never place blankets under the baby or under the belts. Buckle the baby into the seat, and
place blankets over the baby. Therefore this is an incorrect statement and indicates a need for
further instruction. The other statements are correct and indicate no need for further education.
C) Never place blankets under the baby or under the belts. Buckle the baby into the seat, and
D) Never place blankets under the baby or under the belts. Buckle the baby into the seat, and
Page Ref: 2000
Learning Outcome: 2. Identify risk factors and prevention methods associated with motor
vehicle crashes.
68
11) A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle
crash. Which would be the most appropriate intervention for the nurse to include in the plan of
care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.
Answer: C
Explanation: A) Assisting the client to turn at least every 2 hours is the most appropriate
intervention for the nurse to include in the plan of care to reduce the risk of integumentary
complications. Turning the client every 8 hours will not reduce the risk of integumentary
complications. Encouraging exercise improves muscle tone, and encouraging coughing and deep
breathing reduces the risk of respiratory complications, but neither helps reduce the risk of
integumentary complications.
B) Assisting the client to turn at least every 2 hours is the most appropriate intervention for the
nurse to include in the plan of care to reduce the risk of integumentary complications. Turning
the client every 8 hours will not reduce the risk of integumentary complications. Encouraging
exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of
respiratory complications, but neither helps reduce the risk of integumentary complications.
C) Assisting the client to turn at least every 2 hours is the most appropriate intervention for the
D) Assisting the client to turn at least every 2 hours is the most appropriate intervention for the
Page Ref: 2004
Client Need Sub: Basic Care and Comfort
the life span for individuals who have been involved in motor vehicle crashes.
69

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