Post-test SAS 13 NUR 219

A client in the emergency department is suspected of having been raped. The patient
is withdrawn, confused and at times physically withdrawn. As the nurse on duty, you
realize that these behaviors are: *
1 point

Signs of the patients increased risk of suicide

Signs of depression
An indication for the client’s need for admission
Normal reactions to rape or sexual assault

A child was abducted and raped. Which personal reaction by the nurse could interfere
with the child’s care? *
1 point

Concern
Empathy
Anger
Compassion

A person was abducted and raped at gunpoint by an unknown assailant. Which among
the following best indicates that the person is in the immediate and initial stage of rape
trauma? *
1 point

Fears and phobias

Decreased motor activity
Confusion and disbelief
Flashbacks and dreams

Initial intervention for a rape victim should focus on: *

1 point

STD Prophylaxis
Hydration
Oxygenation
Safety and security

The nurse working with a client during a flashback says, “I know you’re scared, but
you’re in a safe place. Do you see the bed in your room? Do you feel the chair you’re
sitting on?” The nurse is using which of the following techniques? *
0 points

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 Distraction
Reality Orientation
Grounding
Relaxation

A client is brought to an emergency department after being violently raped. Which

nursing action is appropriate? *
1 point

Discourage the client from discussing the event as this may lead to further emotional trauma.
Remain non-judgmental and actively listen to the client's description of the event.
Meet the client's self-care needs by assisting with showering and perineal care.
Provide cues, based on police information, to encourage further description of the event.

A college student was raped when out on a date. After several weeks of crisis
intervention therapy, which client statement should indicate to a nurse that the student
is handling this situation in a healthy manner? *
1 point

"I know that it was not my fault."

"If I don't put myself in a dating situation, I won't be at risk."
"My boyfriend has trouble controlling his sexual urges."
"Next time I will think twice about wearing a sexy dress."

Nathan, a 12-year-old child, complains to the school nurse about nausea and
dizziness. While assessing the child, the nurse notices a black eye that looks like an
injury. This is the third time in 1 month that the child has visited the nurse. Each time,
the child provides vague explanations for various injuries. Which of the following is the
school nurse’s priority intervention? *
1 point

Encourage the child to be truthful with her.

Question the teacher about the parent’s behavior.
Report suspicion of abuse to the proper authorities.
Contact the child’s parents and ask about the child’s injury.

Nurse Jessel is observing 8-year-old Andrea during a community visit. Which of the
following findings would lead the nurse to suspect that Andrea is a victim of sexual
abuse? *
1 point

The child has self-injurious behavior.

The child has a lack of peer relationships.
The child is fearful of the caregiver and other adults.
The child has an interest in things of a sexual nature

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 A kindergarten student is frequently violent toward other children. A school nurse
notices bruises and burns on the child's face and arms. What other symptom should
indicate to the nurse that the child might have been physically abused? *
1 point

The child is frequently absent from school.

The child is delayed in physical and emotional development
The child begs or steals food or money.
The child shrinks at the approach of adults.

In a home visit to a family of three: a mother, father, and their child, the mother tells the
community nurse that the father (who is not present) had hit the child on several
occasions when he was drinking. The mother further explains that she has talked her
husband into going to alcoholics support group. She asks the nurse not to interfere, so
her husband won’t get angry and refuse treatment. Which of the following is the best
response of the nurse? *
1 point

The nurse confronts the mother’s failure to protect the child.

The nurse agrees not to interfere if the husband attends an alcoholics support group meeting that evening.
The nurse commends the mother’s efforts and agrees to let her handle things.
The nurse commends the mother’s efforts and also contacts protective services.

Which situation would Nurse Sally identify as placing a client at high risk for caregiver
abuse? *
1 point

Cristina, an elderly adult’s child, quits her job to move in and care for a parent with severe
dementia.
Mr. Yu, an elderly man with severe heart disease, resides in a personal care home and is frequently visited
by his adult child.
Rhea cares for her husband who is in early stages of Alzheimer’s disease and has a network of available
support
Mrs. Rosales, an elderly parent with limited mobility, lives alone and receives help from several adult
children.

Nurse Trent, a community nurse, is conducting a home visit on Mrs. Meyer, a 75 year
old client, who lives with an adult male child. Upon entering the house, Nurse Trent
notes the house is filthy with disarranged furniture, unwashed laundry with rodents
present. As a community nurse, Nurse Trent knows that this form of elderly is: *
1 point

Material Abuse
Neglect Abuse
Physical Abuse
Psychosocial Abuse

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 The interventions common to treatment plans for abuse survivors include which of the
following? Select all that apply: *
1 point

Establish trust and rapport.

Support the client in the decisions he/she makes.
Identify areas of control.
Remove the client from home.
Encourage the client to pursue legal action.

Mrs. Cruz, 70 years old, was admitted to the emergency department of Vicente Sotto
Medical Center with a fractured arm. She explains to the nurse that her injury resulted
when she provoked her drunken son, who then pushed her. Which of the following
best describes the nurse’s understanding of the mother’s explanation? *
1 point

Mrs. Cruz’s explanation is a typical response of a victim accepting blame for the abuser.
Mrs. Cruz’s explanation is an atypical reaction of an abused woman.
Mrs. Cruz’s explanation is evidence that the woman may be an abuser as well as a victim.
Mrs. Cruz’s explanation is appropriate acceptance of her responsibility.

Nathaniel is studying about abuse for the upcoming exam. For her to fully instill the
topic, she should know that the priority nursing intervention for a child or elder victim of
abuse is: *
1 point

Teach appropriate coping skills.

Assess the scope of the abuse problem.
Implement measures to ensure the victim’s safety.
Analyze family dynamics.

When speaking with a mother accused of physical child abuse, the nurse should
expect her to: *
1 point

reveal an overwhelming feeling that her child needed corrective discipline.

ask how she may get permission to visit her son on the pediatric unit.
attempt to rationalize and explain her behavior.
offer a detailed explanation of how her son was injured.

Before helping a client who has been sexually assaulted, the nurse should recognize
that the rapist is motivated by feelings of: *
1 point

inadequacy
hostility
passion

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 incompetence

During a nurse's interview with a client who has been sexually assaulted, the woman
states that she should have fought back. The most therapeutic response by the nurse
would be: *
1 point

"It's over, let's not explore what you could have done."
"You may have submitted, but you are alive".
"It is hard to know, but it's alright now, you are alive".
"You are feeling guilty about submitting".

When working with children who have been sexually abused by a family member, it is
important for the nurse to understand that these victims usually are overwhelmed with
feelings of: *
1 point

humiliation and anger

hatred and revenge
confusion and disbelief
self-blame and guilt

A 13 year old female student tearfully reveals to the school nurse that her brother has
been forcing her to have intercourse. The nurse should: *
1 point

recognize that this revelation is an attention getting method to meet unmeet needs.
accept that this revelation may be a way to explain a suspected pregnancy and refer her for a pregnancy test
suspect that this revelation is a cry for help related to some other crisis.
assume that this revelation is true and follow the school's protocol for investigation.

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