As a mandatory reporter of elder abuse, which of these must be present before a nurse notifies the authorities?
ANS: Suspicion of elder abuse and/or neglect
Many health care workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only a suspicion of elder abuse or neglect is necessary.
During a home visit, the nurse notices that an elderly 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 him
ANS: unintentional physical neglect.
Unintentional physical neglect may occur despite good intentions. It is the failure of the family member or caregiver to provide basic goods or services. Physical abuse is defined as violent acts that result or could r
The nurse is aware that intimate partner violence (IPV) screening should occur with which situation?
ANS: As a routine part of each health care encounter
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?
ANS: "We ask the following questions because domestic violence is so common in our society."
Such an introduction both alerts the woman that questions about domestic violence are coming and makes sure that the woman knows she is not being singled out for
Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface?
ANS: Laceration
The term laceration fits this definition. An abrasion is caused by 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 patient's back. Which of these would cause such an injury?
ANS: Whipping from an extension cord
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 intimate partner violence and elder abuse, the nurse should include:
ANS: photographic documentation of injuries.
Documentation of intimate partner violence and elder abuse must include detailed nonbiased progress notes, the use of injury maps, and photographic documentation. Written documentation needs to be verbatim, wit
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 intimate partner violence. Examples of such conditions include:
ANS: depression.
Depression is one of the conditions that is particularly associated with intimate partner violence. Abused women also have been found to have more chronic health problems, such as neurologic, gastrointestinal, and gynecologic symptoms, an
The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of these statements best describes its use?
ANS: The higher the number of yes answers, the more serious the danger of the woman's situation.
There are no predetermined cutoff scores on the DA. The more yes answers there are, the more serious the danger of the woman's situation. The use of this tool
The nurse is assessing bruising on an injured patient. Which color indicates a new bruise that is less than 2 hours old?
ANS: Red
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 browni
During a home visit, the nurse notices that an elderly woman has very little food in her cabinets or refrigerator and that most of her prescription bottles are empty. She says that she has enough money, but her nephew has her checkbook and he "takes care
ANS: financial neglect.
Financial neglect is failure to use the assets of the elderly person to provide services needed by the elderly person. Financial abuse is intentional misuse of the elderly person's financial or material resources without the inform
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:
ANS: use the words the child has given to describe how the injury occurred.
When documenting the history and physical findings of child abuse and neglect, use the words the child has given to describe how his or her injury occurred. Remember that the abus
During an interview, a woman has answered "yes" to two of the Abuse Assessment Screen questions. What should the nurse say next?
ANS: "Tell me about this abuse in your relationship."
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
The nurse is examining a 3-year-old child who was brought to the emergency room after a fall. Which bruise, if found, would be of most concern?
ANS: Bruising on the abdomen
Studies have shown that children who were walking often had bruises over the bony prominences of the front of their bodies. Other studies have found that bruising in "atypical" places such as the buttocks, hands, feet and abdo
The nurse is assessing an elderly woman and suspects abuse. Which questions are appropriate for screening for abuse? Select all that apply.
ANS: "Has anyone ever physically hurt you?", "Are you alone a lot?", "Are you afraid of anybody at home or anyone who enters your home?", "Has anyone ever failed to help you take care of yourself when you needed help?"
Directly asking "Are you being abuse