NURSING 245: EXAM 2 |109 QUESTIONS AND ANSWERS
(Chapter 7, 13, 14, 15, 16, 17, 19)
As a mandatory reporter of elder abuse, which must be present before a nurse should
notify the authorities?
a.
Statements from the victim
b.
Statements from witnesses
c.
Proof of abuse and/or neglect
d.
Suspicion of elder abuse and/or neglect - -ANS: D
Many health care workers are under the erroneous assumption that proof is required
before notification of suspected abuse can occur. Only the suspicion of elder abuse or
neglect is necessary.
-During a home visit, the nurse notices that an older adult woman is caring for her
bedridden husband. The woman states that this is her duty, she does the best she can, and
her children come to help when they are in town. Her husband is unable to care for himself,
and she appears thin, weak, and exhausted. The nurse notices that several of his
prescription medication bottles are empty. This situation is best described by the term:
a.
Physical abuse.
b.
Financial neglect.
c.
Psychological abuse.
d.
Unintentional physical neglect. - -ANS: D
Unintentional physical neglect may occur, despite good intentions, and is the failure of a
family member or caregiver to provide basic goods or services. Physical abuse is defined as
violent acts that result or could result in injury, pain, impairment, or disease. Financial
neglect is defined as the failure to use the assets of the older person to provide services
needed by him or her. Psychological abuse is defined as behaviors that result in mental
anguish.
-The nurse is aware that intimate partner violence (IPV) screening should occur with
which situation?
a.
When IPV is suspected
b.
When a woman has an unexplained injury
c.
As a routine part of each health care encounter
,d.
When a history of abuse in the family is known - -ANS: C
Many nursing professional organizations have called for routine, universal screening for
IPV to assist women in getting help for the problem.
-Which statement is best for the nurse to use when preparing to administer the Abuse
Assessment Screen?
a.
We are required by law to ask these questions.
b.
We need to talk about whether you believe you have been abused.
c.
We are asking these questions because we suspect that you are being abused.
d.
We need to ask the following questions because domestic violence is so common in our
society. - -ANS: D
Such an introduction alerts the woman that questions about domestic violence are coming
and ensures the woman that she is not being singled out for these questions.
-Which term refers to a wound produced by the tearing or splitting of body tissue, usually
from blunt impact over a bony surface?
a.
Abrasion
b.
Contusion
c.
Laceration
d.
Hematoma - -ANS: C
The term laceration refers to a wound produced by the tearing or splitting of body tissue.
An abrasion is caused by the rubbing of the skin or mucous membrane. A contusion is
injury to tissues without breakage of skin, and a hematoma is a localized collection of
extravasated blood.
-During an examination, the nurse notices a patterned injury on a patients back. Which of
these would cause such an injury?
a.
Blunt force
b.
Friction abrasion
c.
Stabbing from a kitchen knife
d.
Whipping from an extension cord - -ANS: D
A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin
or organ. The other actions do not cause a patterned injury.
, -When documenting IPV and elder abuse, the nurse should include:
a.
Photographic documentation of the injuries.
b.
Summary of the abused patients statements.
c.
Verbatim documentation of every statement made.
d.
General description of injuries in the progress notes. - -ANS: A
Documentation of IPV and elder abuse must include detailed nonbiased progress notes, the
use of injury maps, and photographic documentation. Written documentation needs to be
verbatim, within reason. Not every statement can be documented.
-A female patient has denied any abuse when answering the Abuse Assessment Screen, but
the nurse has noticed some other conditions that are associated with IPV. Examples of such
conditions include:
a.
Asthma.
b.
Confusion.
c.
Depression.
d.
Frequent colds. - -ANS: C
Depression is one of the conditions that is particularly associated with IPV. Abused women
also have been found to have more chronic health problems, such as neurologic,
gastrointestinal, and gynecologic symptoms; chronic pain; and symptoms of suicidality and
posttraumatic stress disorder.
-The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide.
Which of these statements best describes its use?
a.
The DA tool is to be administered by law enforcement personnel.
b.
The DA tool should be used in every assessment of suspected abuse.
c.
The number of yes answers indicates the womans understanding of her situation.
d.
The higher the number of yes answers, the more serious the danger of the womans
situation. - -ANS: D
No predetermined cutoff scores exist on the DA. The higher the number yes answers, the
more serious the danger of the womans situation. The use of this tool is not limited to law
enforcement personnel and is not required in every case of suspected abuse.
, -The nurse is assessing bruising on an injured patient. Which color indicates a new bruise
that is less than 2 hours old?
a.
Red
b.
Purple-blue
c.
Greenish-brown
d.
Brownish-yellow - -ANS: A
A new bruise is usually red and will often develop a purple or purple-blue appearance 12 to
36 hours after blunt-force trauma. The color of bruises (and ecchymoses) generally
progresses from purple-blue to bluish-green to greenish-brown to brownish-yellow before
fading away.
-The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a
leg injury. The best way to document the history and physical findings is to:
a.
Document what the childs caregiver tells the nurse.
b.
Use the words the child has said to describe how the injury occurred.
c.
Record what the nurse observes during the conversation.
d.
Rely on photographs of the injuries. - -ANS: B
When documenting the history and physical findings of suspected child abuse and neglect,
use the words the child has said to describe how his or her injury occurred. Remember, the
abuser may be accompanying the child.
-During an interview, a woman has answered yes to two of the Abuse Assessment Screen
questions. What should the nurse say next?
a.
I need to report this abuse to the authorities.
b.
Tell me about this abuse in your relationship.
c.
So you were abused?
d.
Do you know what caused this abuse? - -ANS: B
If a woman answers yes to any of the Abuse Assessment Screen questions, then the nurse
should ask questions designed to assess how recent and how serious the abuse was. Asking
the woman an open-ended question, such as tell me about this abuse in your relationship is
a good way to start.
-The nurse is examining a 3-year-old child who was brought to the emergency department
after a fall. Which bruise, if found, would be of most concern?
(Chapter 7, 13, 14, 15, 16, 17, 19)
As a mandatory reporter of elder abuse, which must be present before a nurse should
notify the authorities?
a.
Statements from the victim
b.
Statements from witnesses
c.
Proof of abuse and/or neglect
d.
Suspicion of elder abuse and/or neglect - -ANS: D
Many health care workers are under the erroneous assumption that proof is required
before notification of suspected abuse can occur. Only the suspicion of elder abuse or
neglect is necessary.
-During a home visit, the nurse notices that an older adult woman is caring for her
bedridden husband. The woman states that this is her duty, she does the best she can, and
her children come to help when they are in town. Her husband is unable to care for himself,
and she appears thin, weak, and exhausted. The nurse notices that several of his
prescription medication bottles are empty. This situation is best described by the term:
a.
Physical abuse.
b.
Financial neglect.
c.
Psychological abuse.
d.
Unintentional physical neglect. - -ANS: D
Unintentional physical neglect may occur, despite good intentions, and is the failure of a
family member or caregiver to provide basic goods or services. Physical abuse is defined as
violent acts that result or could result in injury, pain, impairment, or disease. Financial
neglect is defined as the failure to use the assets of the older person to provide services
needed by him or her. Psychological abuse is defined as behaviors that result in mental
anguish.
-The nurse is aware that intimate partner violence (IPV) screening should occur with
which situation?
a.
When IPV is suspected
b.
When a woman has an unexplained injury
c.
As a routine part of each health care encounter
,d.
When a history of abuse in the family is known - -ANS: C
Many nursing professional organizations have called for routine, universal screening for
IPV to assist women in getting help for the problem.
-Which statement is best for the nurse to use when preparing to administer the Abuse
Assessment Screen?
a.
We are required by law to ask these questions.
b.
We need to talk about whether you believe you have been abused.
c.
We are asking these questions because we suspect that you are being abused.
d.
We need to ask the following questions because domestic violence is so common in our
society. - -ANS: D
Such an introduction alerts the woman that questions about domestic violence are coming
and ensures the woman that she is not being singled out for these questions.
-Which term refers to a wound produced by the tearing or splitting of body tissue, usually
from blunt impact over a bony surface?
a.
Abrasion
b.
Contusion
c.
Laceration
d.
Hematoma - -ANS: C
The term laceration refers to a wound produced by the tearing or splitting of body tissue.
An abrasion is caused by the rubbing of the skin or mucous membrane. A contusion is
injury to tissues without breakage of skin, and a hematoma is a localized collection of
extravasated blood.
-During an examination, the nurse notices a patterned injury on a patients back. Which of
these would cause such an injury?
a.
Blunt force
b.
Friction abrasion
c.
Stabbing from a kitchen knife
d.
Whipping from an extension cord - -ANS: D
A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin
or organ. The other actions do not cause a patterned injury.
, -When documenting IPV and elder abuse, the nurse should include:
a.
Photographic documentation of the injuries.
b.
Summary of the abused patients statements.
c.
Verbatim documentation of every statement made.
d.
General description of injuries in the progress notes. - -ANS: A
Documentation of IPV and elder abuse must include detailed nonbiased progress notes, the
use of injury maps, and photographic documentation. Written documentation needs to be
verbatim, within reason. Not every statement can be documented.
-A female patient has denied any abuse when answering the Abuse Assessment Screen, but
the nurse has noticed some other conditions that are associated with IPV. Examples of such
conditions include:
a.
Asthma.
b.
Confusion.
c.
Depression.
d.
Frequent colds. - -ANS: C
Depression is one of the conditions that is particularly associated with IPV. Abused women
also have been found to have more chronic health problems, such as neurologic,
gastrointestinal, and gynecologic symptoms; chronic pain; and symptoms of suicidality and
posttraumatic stress disorder.
-The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide.
Which of these statements best describes its use?
a.
The DA tool is to be administered by law enforcement personnel.
b.
The DA tool should be used in every assessment of suspected abuse.
c.
The number of yes answers indicates the womans understanding of her situation.
d.
The higher the number of yes answers, the more serious the danger of the womans
situation. - -ANS: D
No predetermined cutoff scores exist on the DA. The higher the number yes answers, the
more serious the danger of the womans situation. The use of this tool is not limited to law
enforcement personnel and is not required in every case of suspected abuse.
, -The nurse is assessing bruising on an injured patient. Which color indicates a new bruise
that is less than 2 hours old?
a.
Red
b.
Purple-blue
c.
Greenish-brown
d.
Brownish-yellow - -ANS: A
A new bruise is usually red and will often develop a purple or purple-blue appearance 12 to
36 hours after blunt-force trauma. The color of bruises (and ecchymoses) generally
progresses from purple-blue to bluish-green to greenish-brown to brownish-yellow before
fading away.
-The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a
leg injury. The best way to document the history and physical findings is to:
a.
Document what the childs caregiver tells the nurse.
b.
Use the words the child has said to describe how the injury occurred.
c.
Record what the nurse observes during the conversation.
d.
Rely on photographs of the injuries. - -ANS: B
When documenting the history and physical findings of suspected child abuse and neglect,
use the words the child has said to describe how his or her injury occurred. Remember, the
abuser may be accompanying the child.
-During an interview, a woman has answered yes to two of the Abuse Assessment Screen
questions. What should the nurse say next?
a.
I need to report this abuse to the authorities.
b.
Tell me about this abuse in your relationship.
c.
So you were abused?
d.
Do you know what caused this abuse? - -ANS: B
If a woman answers yes to any of the Abuse Assessment Screen questions, then the nurse
should ask questions designed to assess how recent and how serious the abuse was. Asking
the woman an open-ended question, such as tell me about this abuse in your relationship is
a good way to start.
-The nurse is examining a 3-year-old child who was brought to the emergency department
after a fall. Which bruise, if found, would be of most concern?
