NCLEX ( 50 questions) on PTSD/Anger/Abuse (2020)
NCLEX ( 50 questions) on PTSD/Anger/Abuse
1.) A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed?
1. “The trauma that women experience is more likely to be sexual assault and child sexual abuse.”
2. “The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury.”
3. “After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD).”
4. “Research shows that PTSD is more common in men than in women.”
Rationale: Research shows that PTSD is more common in women than in men. This student statement indicates a need for further instruction.
2.) Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)?
1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events.
2. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to “normal” daily events.
3. Depressive symptoms occur in PTSD and not in AD.
4. Depressive symptoms occur in AD and not in PTSD.
Rationale: PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events, such as divorce, failure, or rejection. Depressive symptoms can occur in both PTSD and AD.
3.) Which client would a nurse recognize as being at highest risk for the development of an AD?
1. A young married woman
2. An elderly unmarried man
3. A young unmarried woman
4. A young unmarried man
Rationale: Adjustment disorders are more common in women, unmarried persons, and younger people. Although more common in the young, it can occur at any age.
4.) A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that learning has occurred?
1. “How clients perceive events and view the world affect their response to trauma.”
2. “The psychic numbing in PTSD is a result of negative reinforcement.”
3. “The individual becomes addicted to the trauma owing to an endogenous opioid response.”
4. “Believing that the world is meaningful and controllable can protect an individual from PTSD.”
Rationale: Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. Psychic numbing decreases or protects an individual from emotional pain and, therefore, the learned response is the repetition of this behavior.
5.) As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client’s symptom?
2. Altered thought processes
3. Complicated grieving
4. Altered sensory perception
Rationale: The client’s survivor guilt is disrupting the normal process of grieving. Although the client may also experience anxiety, the symptom presented in the question is extreme guilt. There is no evidence presented in the question to indicate altered thought or altered sensory perception.
6.) A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ?
1. Encourage the journaling of feelings.
2. Assess for the stage of grief in which the client is fixed.
3. Provide community resources to address the client’s concerns.
4. Encourage attending a grief therapy group.
Rationale: Prior to implementing all other nursing interventions presented, the nurse must assess the stage of grief in which the client is fixed. Appropriate nursing interventions are always based on accurate assessments.
7.) Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)?
1. Anxiety, feelings of hopelessness, and worry
2. Truancy, vandalism, and fighting
3. Nervousness, worry, and jitteriness
4. Depressed mood, tearfulness, and hopelessness
Rationale: AD with depressed mood is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depression. The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what is an expected or normative response to an identified stressor.
8.) Both situational and intrapersonal factors most likely contribute to an individual’s stress response. Which factor would a nurse categorize as intrapersonal?
1. Occupational opportunities
2. Economic conditions
3. Degree of flexibility
4. Availability of social supports
Rationale: Intrapersonal factors that might influence an individual’s ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence.
9.) A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this client’s problem?
1. Rates anxiety as 4 out of 10 by discharge.
2. States anxiety level has decreased by day one.
3. Accomplishes activities of daily living independently.
4. Demonstrates ability for adequate social functioning by day three.
Rationale: An outcome statement must be client-centered, specific, measurable, and contain a time frame, so that it can be evaluated effectively. A “decrease” in anxiety is vague rather than specific, and expecting an anxiety decrease by day one may also be unrealistic. Accomplishing activities of daily living independently and demonstrating the ability for adequate social functioning do not address the anxiety nursing diagnosis.
10.) Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder?
1. Adjustment disorder
2. Generalized anxiety disorder
3. Panic disorder
4. Post-traumatic stress disorder
Rationale: EMDR has been used for depression, adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic disorder. However, at present, EMDR has only been empirically validated for trauma-related disorders such as PTSD and acute stress disorder.
11.) After a teaching session about grief, a client says to the nurse, “I seem to be stuck in the anger stage of grieving over the loss of my son.” How would the nurse assess this statement, and in what phase of the nursing process would this occur?
1. Assessment phase; nursing actions have been successful in achieving the objectives of care.
2. Evaluation phase; nursing actions have been successful in achieving the objectives of care.
3. Implementation phase; nursing actions have been successful in achieving the objectives of care.
4. Diagnosis phase; nursing actions have been successful in achieving the objectives of care.
Rationale: In the evaluation phase of the nursing process, reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. The implementation of client teaching has enabled the client to verbalize an understanding of the grief process and his or her position in the process. Therefore, the nurse’s actions can be evaluated as successful.
12.) By which biological mechanism does EMDR achieve its therapeutic effect?
1. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown.
2. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness.
3. EMDR achieves its therapeutic effect by causing an increase in memory access.
4. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.
Rationale: Some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory access. EMDR is thought to relieve anxiety associated with the traumatic event. However, the exact biological mechanisms by which EMDR achieves its therapeutic effects are unknown
13.) A client receiving EMDR therapy says, “After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life.” Which of the following nursing responses is most appropriate?
1. “I am thrilled that you have responded so rapidly to EMDR.”
2. “To achieve lasting results, all eight phases of EMDR must be completed.”
3. “If I were you, I would complete the EMDR and comply with doctor’s orders.”
4. “How do you feel about continuing the therapy?”
Rationale: Clients often feel relief quite rapidly with EMDR. However, to achieve lasting results, it is important that each of the eight phases be completed. The nurse’s most appropriate response should be to give information to correct the client’s misconceptions about the therapy. In answer 3 the nurse is subjectively giving advice rather than providing objective information.
14.) A nurse would recognize which treatment as most commonly used for AD and its appropriate rationale?
1. Psychotherapy; to examine the stressor and confront unresolved issues
2. Fluoxetine (Prozac); to stabilize mood and resolve symptoms
3. Eye movement desensitization therapy; to reprocess traumatic events
4. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety
Rationale: Psychotherapy is the most common treatment used for AD. AD is not commonly treated with medications. Anxiolytic and antidepressant medications may be prescribed as adjuncts to psychotherapy but should not be given as the first line of treatment. Eye movement desensitization and reprocessing therapy is not used to treat adjustment disorders.
15.) A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client’s plan of care?
1. The client will have no flashbacks.
2. The client will be able to feel a full range of emotions by discharge.
3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
4. The client will refrain from discussing the traumatic event.
Rationale: Obtaining adequate sleep without zolpidem by discharge is a goal that should be included in the client’s plan of care. Having no flashbacks and experiencing a full range of emotions by discharge are unrealistic goals. Clients are encouraged, not discouraged, to discuss the traumatic event.
16.) A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication?
1. Flat affect and anhedonia
2. Persistent anorexia and 10 lb weight loss in 3 weeks
3. Flashbacks of killing the enemy
4. Distant and guarded in relationships
Rationale: The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone. Paliperidone is an antipsychotic medication that will address the symptoms of psychosis.
17.) A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis?
1. The client worries continually and appears nervous and jittery.
2. The client complains of a depressed mood, is tearful, and feels hopeless.
3. The client is belligerent, violates others’ rights, and defaults on legal responsibilities.
4. The client complains of many physical ailments, refuses to socialize, and quits her job.
Rationale: The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, social withdrawal, or work or academic inhibition, without significant depressed or anxious
18.) A client has been extremely nervous ever since a person died as a result of the client’s drunk driving. When assessing for the diagnosis of AD, within what time frame should the nurse expect the client to exhibit symptoms?
1. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within one year of the accident.
2. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within three months of the accident.
3. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within six months of the accident.
4. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within nine months of the accident.
Rationale: According to the DSM-5 diagnostic criteria for adjustment disorders, the development of emotional or behavioral symptoms in response to an identifiable stressor occurs within three months of the onset of the stressor.
19.) A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder?
1. The 60-year-old, because of memory deficits.
2. The 60-year-old, because of decreased cognitive processing ability.
3. The 20-year-old, because of limited cognitive experiences.
4. The 20-year-old, because of lack of developmental maturity.
Rationale: Research indicates that there is a predisposition to the diagnosis of adjustment disorder when there is limited developmental maturity. By comparison, the 20-year-old does not have the developmental maturity, life experiences, and coping mechanisms that the 60-year-old might possess.
20.) A client diagnosed with an adjustment disorder says to the nurse, “Tell me about medications that will cure this problem.” Which of the following are appropriate nursing responses? (Select all that apply.)
1. “Medications can interfere with your ability to find a more permanent problem solution.”
2. “Medications may mask the real problem at the root of this diagnosis.”
3. “Adjustment disorders are not commonly treated with medications.”
4. “Psychoactive drugs carry the potential for physiological and psychological dependence.”
5. “Psychoactive drugs will be prescribed only if your problems persist for more than three months.”
Rationale: Adjustment disorders are not commonly treated with medications because of temporary effects, masking the real problem, interfering with finding a permanent solution, and the potential for addiction.
21.) A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.)
1. Feelings of guilt that precipitate social isolation
2. Aggressive behavior that affects job performance
3. Relationship problems
4. High levels of anxiety
5. Escalating symptoms lasting less than one month
Rationale: Characteristic symptoms of PTSD include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, general numbing of responsiveness, nightmares, inability to remember certain aspects of the traumatic event, depression, guilt feelings, substance abuse, anger, and aggressive behaviors. The full-symptom picture must present for more than one month and cause significant interference with social, occupational, and other areas of functioning.
22.) A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.)
1. An individual’s religious affiliation can affect response to trauma.
2. Responses are affected by how an individual handled previous trauma.
3. Protectiveness of family and friends can help an individual deal with trauma.
4. Control over the possibility of recurrence can affect the response to trauma.
5. The time in which the trauma occurred can affect the individual’s response.
Rationale: Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of (1) the traumatic experience, (2) the individual, and (3) the recovery environment. All information presented falls under one of these groups. Spiritual beliefs, which can be considered a cultural influence, can affect the individual’s response, however, an individual’s specific religious affiliation should have no bearing or influence.
23.) A nurse would recognize which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.)
1. The severity of the stressor
2. The degree of ego strength
3. The degree of psychosocial isolation in the recovery environment
4. The attitudes of society regarding the experience
5. The presence of preexisting psychopathology
Rationale: In research with Vietnam veterans, it was shown that the best predictors of PTSD were the severity of the stressor and the degree of psychosocial isolation in the recovery environment.
24.) A client diagnosed with PTSD states, “Why did my doctor prescribe an antidepressant rather than an antianxiety drug for me?” Which of the following are the most appropriate nursing responses? (Select all that apply.)
1. “I’m not sure, because antianxiety drugs have been approved by the FDA for PTSD.”
2. “Antidepressants are now considered first-line treatment choice for PTSD.”
3. “Many people have adverse reactions to antianxiety drugs.”
4. “Because of their addictive properties, antianxiety drugs are less desirable.”
5. “There have been no controlled studies on the effect of antianxiety drugs on PTSD.”
Rationale: Antidepressants are now considered the first-line treatment of choice for PTSD. There has been an absence of controlled studies demonstrating the efficacy of benzodiazepines for the treatment of PTSD. Their addictive properties make them less desirable than other medications used in the treatment of PTSD. Paroxetine and sertraline (antidepressant drugs), not antianxiety drugs, have been approved by the FDA for the treatment of PTSD. Adverse reactions can occur with the use of anxiolytic drugs, but these reactions are not common.
25.) Jared returned from active duty in the military and has been diagnosed with PTSD. Which of the following interventions has been strongly advocated for as an effective strategy in this population?
1) Group therapy with patients who have a variety of diagnoses
2) Group therapy with patients who have anger management issues
3) Group therapy with patients who have experienced similar traumas
4) Group therapy with patients who have experienced different types of trauma
Rationale: This type of group therapy is strongly recommended so that veterans may be able to share experiences with other veterans (and therefore similar traumatic events) to decrease feelings of isolation.
26.) The family of a patient being treated for PTSD asks the nurse to describe EMDR (eye movement desensitization and reprocessing), since it is being recommended for this patient. Which of the following teaching points are accurate descriptions of this intervention? Select all that apply.
1) EMDR has been shown to be effective in the treatment of all mental illnesses, including schizophrenia.
2) The process involves rapid eye movement while processing painful memories.
3) This process is contraindicated for patients with retinal detachment or glaucoma.
4) This process is thought to relieve anxiety so that the trauma can be processed from a more detached perspective.
5) The biological mechanism that makes EMDR effective is that it releases opioid-like chemicals in the brain.
27.) The nurse is developing a plan of care for a patient diagnosed with PTSD. Which of the following variables will have an impact on the patient's response to interventions? Select all that apply.
1) Patient's self-esteem
2) Socioeconomic status
3) History of psychopathology
4) Amount of control over recurrence
6) Immediate crisis debriefing
28.) Carol has sought treatment for an adjustment disorder after divorcing her husband of 30 years. The nurse assesses that Carol is experiencing complicated grieving. Which of the following would be an appropriate intervention to address Carol's symptoms?
1) Explore with Carol the stages of normal grieving.
2) Tell Carol that expressing anger will only keep her fixated at that stage of grieving.
3) Encourage Carol that these symptoms usually go away on their own.
4) All of the above.
Rationale: It is appropriate to encourage exploration and identification of which stage of grieving Carol is currently experiencing.
29.) John has been in counseling for an adjustment disorder related to losing his management position in a health care facility. He tells the counselor he feels ready to terminate counseling. Which of these statements by the patient supports his readiness to terminate counseling?
1) "Counseling isn't going to get me another job, so what's the point?"
2) "I don't feel angry anymore and I've learned how to relax better."
3) "I've decided I'm never going to work again, so I'm applying for disability."
4) "As long as I continue to take antianxiety medication, I'll be okay."
Rationale: This response demonstrates progression through the grieving process and use of an appropriate coping skill.
30.) During a psychiatric nursing assessment, Sally reports to the nurse that she was sexually assaulted 6 months ago and since then has had trouble concentrating at work. Her employer tells her he is sensitive to the amount of stress she is under, since she also recently went through a divorce, but that she needs to seek help for her anxiety and depression to avoid further consequences at work. Which of these data support the diagnosis of PTSD according to DSM-5 criteria? Select all that apply.
1) She directly experienced a traumatic event.
2) She is a single female.
3) She has had difficulty concentrating at work.
4) Her anxiety and depression are interfering with job functioning.
5) Her symptoms have been present for more than 6 months.
Rationale: 1: Exposure to actual or threatened death, serious injury, or sexual violence is defined as trauma that meets diagnostic criteria for PTSD according to the DSM-5. 3: Problems with concentration that are associated with traumatic events are identified in DSM-5 as part of the diagnostic criteria for PTSD. 4: Clinically significant impairment in occupational function is a diagnostic criterion for PTSD, according to the DSM-5. 5: Symptoms present for more than 1 month warrant a diagnosis of PTSD.
31.) An adult male has sought counseling at a community mental health center for PTSD. He reports during assessment that he witnessed the murder of a close friend last year in a random, drive-by shooting in his neighborhood. Since this loss he has had recurrent nightmares, explosive episodes, and frequently incapacitating anxiety. Which of the following nursing diagnoses would be appropriate, based on this assessment data? Select all that apply.
1) Post Trauma Syndrome R/T distressing events, as evidenced by recurrent nightmares.
2) Complicated grieving R/T loss of a friend in the traumatic event, as evidenced by explosive outbursts and reports of incapacitating anxiety.
3) Isolation R/T unresolved anxiety, as evidenced by complaints of incapacitating anxiety.
4) Risk for suicide R/T survivor guilt.
Rationale: 1: Recurrent nightmares connected to the experience of a traumatic experience indicate that Post Trauma Syndrome is an appropriate nursing diagnosis. 2: The experience of significant psychological and/or physiological distress in response to a loss implies that complicated grieving is an appropriate nursing diagnosis.
32.) A patient with PTSD who has been having nightmares is prescribed propranolol to treat PTSD symptoms. He asks the nurse why this medication was ordered since he doesn't have high blood pressure. Which of the following is the most appropriate response by the nurse at this point?
1) Call the doctor and question this order.
2) Discontinue the medication and check the patient's blood pressure.
3) Explain that propranolol has been shown to be effective in reducing nightmares associated with PTSD.
4) Explain that this medication is used to treat hypertension that often accompanies PTSD.
Rationale: There is established evidence that propranolol is effective in reducing nightmares associated with PTSD, and this response addresses the immediate client need for information about the medication ordered.
33.) Jennifer is working with the nurse on her care plan related to post trauma syndrome. Jennifer repeatedly asks the nurse why she is writing down everything and who will be seeing this information. Which of these interpretations by the nurse reflects an understanding of the post trauma patient?
1) Post trauma patients may be suspicious of others in their environment.
2) Post trauma patients need a lot of redirection.
3) Female post trauma patients are often very confused about details.
4) Post trauma patients are always confrontational and challenging with health care professionals.
Rationale: An understanding that post trauma patients may be suspicious of others in the environment will assist the nurse in responding to the patient in a manner that promotes trust between them.
34.) A female patient, Sally, was admitted to the psychiatric inpatient unit with PTSD following a rape 6 months ago in which she suffered several physical injuries. This evening she was approached from behind by a male patient who touched her on the shoulder, and Sally began screaming "I'm going to kill you for what you did to me!" Which of these immediate interventions by the nurse demonstrates a safe and effective care environment? Select all that apply.
1) Place the patient in seclusion for the safety of others.
2) Offer the patient reassurance that she is in a safe environment.
3) Tell the patient to share the details that she remembers about the traumatic event.
4) Stay with the patient.
5) Acknowledge and validate the patient's feelings as they are expressed.
35.) The nurse is conducting an assessment for a patient diagnosed with PTSD. She recognizes that people with PTSD are at high risk for several comorbid conditions. Which of the following will she need to assess carefully because of the high risk in people with PTSD? Select all that apply.
2) Depression and suicide ideation
3) Substance abuse
4) Verbal or physical aggression
5) Narcissistic Personality Disorder
36.) Beth is being treated for an adjustment disorder following a job demotion 2 months ago. Since the demotion, she has frequently called in sick, complains of incapacitating migraines, and has been disciplined for yelling at her boss. Her husband asks the nurse why his wife is still having so much trouble functioning, since he knows people who have lost their jobs entirely and have since resolved their concerns. Which of these statements by the nurse accurately reflects understanding of the dynamics of different kinds of stressors in patient recovery?
1) Women have more difficulty managing work-related stressors than men.
2) Ongoing stressors are associated with more maladaptive behaviors than sudden-shock types of stressors.
3) Job demotion is associated with longer-term recovery because it is so uncommon.
4) Carol probably had pre-existing difficulties managing stressors as a child.
Rationale: There is evidence that continuous stressors are associated with more maladaptive behaviors than sudden-shock stressors.
37.) A patient admitted to the psychiatric unit, who has been experiencing flashbacks and troubling nightmares, reports to the nurse that he just awoke from a nightmare and is still having chest pain. Which of these nursing interventions is a priority?
1) Encourage the patient to return to bed and try to calm down.
2) Administer prn antianxiety medication as ordered.
3) Assess the patient's cardiovascular status.
4) Encourage the patient to reflect on the troubling dream.
Rationale: This intervention is the most important priority since complaints of chest pain should not be assumed to be solely anxiety symptoms. The patient may be having a heart attack.
38.) The nurse is conducting an intake assessment for a patient with PTSD. Which of the following pieces of information support this diagnosis? Select all that apply.
1) The patient reports having nightmares but can't remember what they are about.
2) The patient states that he heard a loud noise when he was walking down the street and thought he was back in the war zone where he had last been deployed.
3) The patient took antidepressants when he was in junior high school and reports they didn't help.
4) The patient denies any history of substance abuse or dependence.
39.) A patient who has recently been diagnosed with PTSD asks the nurse what his options are for treatment of this disorder. Which of the following items should the nurse include in teaching the patient about primary treatments for PTSD? Select all that apply.
1) Prolonged exposure therapy
2) Cognitive therapy
4) Antipsychotic medication
40.) One type of intervention useful for patients with adjustment disorders is a short-term therapy focused on problem-solving skills and restoring adaptive functioning. This type of therapy is ____________________.
Answer: Crisis intervention
Rationale: The goal of this therapy is to mobilize resources needed to resolve the crisis situation. It is relevant in the treatment of adjustment disorders since a lack of adequate coping skills and resources contributes to the development of this condition
41.) Because severely battered women are at risk for homicide, what responsibility does the nurse have in providing appropriate care?
1) Encourage the client to leave the unsafe situation and not to return to the abusive relationship.
2)Inform the client about associated risk factors and determine the immediacy of danger.
3)Ask the client's permission to inform the police and assess the need for protection from the abuser.
4)Remain nonjudgmental and do not give advice about what the client needs to do.
42.) How can nurses create safer communities and reduce the threats of violence?
1) Provide inservice training to other health care professionals.
2) Become a political advocate and help create social policies.
3) Provide community educational programs on violence prevention.
4) All of the above
43.) Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case?
1) Flexible role functioning between parents
2) History of the parent having been abused as a child
3) Single-parent home situation
4) Presence of parental mental illness
44.) A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned?
1) Family violence affects every socioeconomic level.
2) Family violence is caused by drugs and alcohol abuse.
3) Family violence predominantly occurs in lower socioeconomic levels.
4) Family violence rarely occurs during pregnancy.
45.) During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except:
1) conflictual relationships of parents.
2) inconsistent communication patterns.
3) rigid, authoritarian roles.
4) use of violence to establish control.
46.) During a home visit to a family of three: a mother, a father, and their child, The mother tells the community nurse that the father (who is not present) has hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and 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) The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening.
2) The nurse commends the mother’s efforts and agrees to let her handle things.
3) The nurse commends the mother’s efforts and also contacts protective services.
4) The nurse confronts the mother’s failure to protect the child.
47.) Joseph, 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) Contact the child’s parents and ask about the child’s injury.
2) Encourage the child to be truthful with her.
3) Question the teacher about the parent’s behavior.
4) Report suspicion of abuse to the proper authorities.
48.) Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse?
1) The child is fearful of the caregiver and other adults.
2) The child has a lack of peer relationships.
3) The child has self-injurious behavior.
4) The child has interest in things of a sexual nature
49.) Nurse Angela is working in the emergency department of Nurseslabs Medical Center. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first?
1) Contact the appropriate legal services.
2) Ensure privacy for interviewing the victim away from the abuser.
3) Establish a rapport with the victim and the abuser.
4) Request the presence of a security guard.
50.) A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the young children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation?
1) Delayed growth and development, related to performance expectations of child.
2) Anxiety (moderate), related to difficulty managing home situation.
3) Impaired parenting, related to role reversal of mother and child.
4) Social isolation, related to lack of extended family assistance.