A)

B)
C)
D)

1.When planning care for the client who is at risk for self-injury, the nurse would include
which of the following interventions?
Allowing the client to select which activities to attend
Consistent time-out schedule for unacceptable behavior
No self-harm contract
Point system for earning privileges

A)
B)
C)
D)

2.The police find a woman wandering around a parking lot, singing very loudly. They bring
her to the hospital; she has no knowledge of what she has been doing for the past 12
hours and is dressed in unfamiliar clothing. This is an example of
Dissociation
Manipulation
Psychosis
Regression

A)
B)
C)
D)

3.Which of the following is true about the use of touch with a client with dissociative
identity disorder?
It is best not to touch the client without his or her permission.
Make sure the client knows the touch is friendly and supportive.
Touch the client only if you are in his or her direct line of vision.
Touching will convey a sense of security to the client.

A)
B)
C)
D)

4.The nurse is caring for a 16-year-old boy with a history of sexual abuse. The nurse might
expect this adolescent to
Experience nightmares and flashbacks
Have no ill effects due to his age
Reject his mother for not protecting him
Want to confront the perpetrator

A)
B)
C)
D)

5.Which of the following behaviors would first alert the school nurse or teacher to suspect
sexual abuse in a 7-year-old child?
Extreme friendliness to peers
Learning problems and shyness
Telling sexually explicit stories to peers
Withdrawn behavior and enuresis

A)
B)
C)
D)

6.The nurse is working in the emergency department with a woman who was raped 1 hour
ago. In planning care, it is important for the nurse to remember which of the following?
Angry feelings need to be set aside until physical care is completed.
Evidence collection according to procedures is the priority.
The nurse will need to make decisions for this client.
The woman may feel threatened by some of the procedures.
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D)

7.A frightened young woman calls the emergency department and tearfully tells the nurse,
I've been raped! Please help me! Before telling the client what to do, the nurse would
need to know if
If the client was injured, was in a safe place, and had transportation available
If the client knew her assailant, knew her location, and had notified the police
If she has insurance, if she could get to the hospital by herself, and if pregnancy is a
possibility
If she had bathed, douched, or changed clothes

A)
B)
C)
D)

8.A female college student comes to the counseling center and tells the nurse she is afraid
of her boyfriend. She states, He is so jealous and overprotective; he wants to know
where I am and who I'm with every minute. The nurse recognizes this as which of the
following?
An overreaction on the part of the student
A situation requiring a restraining order
The boyfriend is insecure and needs reassurance
The tension-building phase of the violence cycle

A)
B)
C)
D)

9.The nurse is working with a client at the battered women's shelter who is in a violent and
abusive relationship. The client is considering a separation and asks the nurse, What do
you think about that? The best response by the nurse is,
Batterers never change, so it would be best for you to leave.
If you don't leave, he'll think you're going to continue to endure his abuse.
If you leave, maybe he'll see that he has to change his behavior.
You may be in more physical danger after you leave him.

A)
B)
C)
D)

10.The nurse is assessing an elderly female in the emergency department. There are many
bruises present on her body in varying stages of healing. After documenting the bruising
in the assessment, what should the nurse do next?
Ask the client when and how the bruises occurred
Call the nursing supervisor immediately
Follow the facility's policy and procedures for reporting abuse
Notify the physician that abuse is suspected

A)
B)
C)
D)

11.The nurse is collecting assessment data on a patient who is suspected to be a victim of

violence. The nurse would note which assessment data to support the suspicion that the
patient is a victim of abuse? (Select all that apply)
Has few friends
Holds a dominant role in the family
Is in charge of the family finances
Moderate amount of alcohol use in the home

A)
B)
C)

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E)

Reports father was abusive during childhood

A)
B)
C)
D)

12.A young female Mexican immigrant presents in the rural health clinic with facial bruising
and a fractured nose. The patient is reluctant to give details of the nature of her injuries.
The nurse understands which of the following as a consideration in providing care for this
patient?
Most views regarding domestic violence are universal across cultures
She may fear deportation if she seeks public assistance
Immigrants have expedited access to public legal services
A translator is required for her to adequately disclose her concerns

A)
B)
C)
D)

13.In completing the family assessment of a victim on intimate partner violence, the nurse
looks for which of the following characteristics in the abuser?
Encourages the partner to have a life outside the intimate relationship
An inflated sense of self-esteem
Needy and possessive of the partner
An ability to feel remorse for the abuse

A)
B)
C)
D)

14.The nurse is involved in a community education program for new parents and plans to
include information on child abuse. The nurse will teach the parents that the most
common form of child abuse is which of the following?
Neglect
Physical abuse
Sexual abuse
Emotional abuse

A)
B)
C)
D)

15.A coherent elderly woman has been financially and emotionally abused by her adult
children for the past several years, but has failed to report the abuse to anyone. The most
likely reason for neglecting to report the abuse includes which of the following?
She cannot claim abuse if there is no evidence of physical harm
Laws do not provide protection against abuse when the suspect(s) is/are family
members
She has no financial resources to hire legal representation against her children
She is emotionally close to her children and does not want to bring them harm

16.A school nurse is educating a group of adolescent girls about rape and sexual assault. The
nurse evaluates the students understanding when they report which of the following as
high risk factors regarding the incidence of rape?
A)
The highest incidence of rape occurs in adolescents and young adults women
B)
Most rapes are committed by strangers
C)
Most rapes are random acts of violence

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D)

A victim is at highest risk in unfamiliar neighborhoods

A)
B)
C)
D)

17.Elder abuse is the maltreatment of older adults by family members or caregivers.

Approximately what percentage of perpetrators of elder abuse are adult children?
20%
40%
60%
80%

A)
B)
C)
D)

18.A patient is seeking counseling due to difficulty coping with being a victim of a violent
attack 16 months ago. The initial medical diagnosis is rule out Posttraumatic Stress
Disorder (PTSD). During the history the nurse assesses for which of the following to
support the diagnosis of PTSD?
Complaints of exhaustion and increased amounts of sleep
Obsession to return to the location of the attack to try to resolve the trauma
Avoidance of discussing the details of the attack
Inability to notice environmental stimuli

A)
B)
C)
D)

19.A man is discovered wandering the street, looking confused and stepping out into traffic.
When emergency responders approach the man, he cannot recall his name or where he
lives. The responders transport the man to the mental health crisis unit for further
evaluation. Given only this information, the man is most likely suffering from which of
the following?
Depersonalization disorder
Dissociative identity disorder
Dissociative fugue
Dissociative amnesia

A)
B)
C)
D)

20.A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually
abused repeatedly by her husband. Which of the following interventions would be
appropriate in relation to this data?
Avoid discussing the abuse so as not to upset her
Encourage her to talk about feelings related to the abuse
Request an anxiolytic to reduce her anxiety levels
Help her explore her role in perpetuating the abuse

21.The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital
for a fractured femur. Which of the following data obtained during the assessment would
raise the nurses suspicion that the child has suffered physical abuse?
A)
The parents appearing overprotective of the child
B)
Bruises over the childs boney prominences

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C)
D)

The injury occurring several days before the parents sought treatment
Both parents reporting the exact same details pertaining to the injurious event

A)
B)
C)
D)

22.A woman has just presented at the emergency department after being raped. The initial
nursing action would be:
Provide emotional support
Refer her to a rape crisis hotline
Encourage her to file charges immediately
Perform a nursing history and physical as quickly as possible

A)
B)
C)
D)

23.A victim of spousal abuse states, Why do I keep putting put up with this? I am so weak.
The best response by the nurse would be:
I can help you gain the strength to leave.
Why do you stay in the relationship?
That is a very common reaction to domestic abuse.
You feel helpless to change anything.

A)
B)
C)
D)

24.A fireman survived a fire after escaping a blaze. Several other firefighters were trapped in
the burning building and died. After working with this firefighter in counseling, the nurse
evaluates which of the following as a positive outcome for this patient?
The patient will verbalize an absence of stress related to returning to work
The patient will express guilt openly through non-destructive means
The patient will express an ability to be self-sufficient in meeting own needs
The patient will report nightmares and flashbacks of the fire

A)
B)
C)
D)

25.The school nurse is teaching a health class about recognizing the signs of abusive
relationships. The nurse describes the cycle of violence. The nurse would document
effective teaching if the students identify the cycle of violence to be which of the
following patterns? (Select the order in which the events occur)
Tension building
Honeymoon period
Violent behavior
Period of remorse

A)
B)
C)
D)

26.The nurse is discussing expectations of raising a child with a pregnant teenager expecting
her first baby. The father will not be a participant in the parenting. Which of the following
statements made by the expectant mother would be of greatest concern to the nurse?
I am going to rely on my sisters for a lot of help raising my baby.
I was raised with very strict discipline.
My child will love me unlike my parents ever did.
I am not sure how I am going to pay for all the things my child will need.

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B)
C)
D)

27.The community health nurse meets with the family members of an elderly patient. The
nurse includes which of the following in the plan of care as a preventive measure to guard
against elder abuse?
Reassure the primary caregiver that they are in the best position to provide care to
the elder
Teach the primary caregiver skills to meet all of the elders needs
Assist in the transfer of legal authority for elder care to the primary caregiver
Provide the primary caregiver with additional resources to meet the elders needs

A)
B)
C)
D)

28.The nurse at a university health services clinic has been asked to meet with a freshman
class of women about warning signs of relationship violence. The nurse points out which
of the following danger signs the students should be alert for in a date?
Dislikes your fiends
Acts indifferent to your life choices
Is excessively jealous
Views you as superior to himself

A)
B)
C)
D)

29.A nurse is working with a patient who has a history of repeated abusive intimate
relationships. The nurse has difficulty understanding why a woman would repeatedly
enter into relationships with abusive partners. When working with this patient, the nurse
can best maintain a therapeutic relationship through which of the following approaches?
Keeping focused on the patients feelings about her life situation
Honestly asking the patient why she repeats the cycles of victimization
Convincing the patient to develop a self-rescue plan
Not prying into the details of the patients private life

A)
B)
C)
D)

30.When the client has episodes of suddenly leaving home without any explanation, this is
documented as which of the following?
Depersonalization disorder
Dissociative fugue
Dissociative amnesia
Dissociative identity disorder

A)

Page 6

Answer Key
1.C
2.A
3.A
4.A
5.C
6.D
7.A
8.D
9.D
10.A
11.A, D, E
12.B
13.C
14.A
15.D
16.A
17.A
18.C
19.D
20.B
21.C
22.A
23.D
24.B
25.A, B, C, D
26.C
27.D
28.C
29.A
30.B

Page 7