Question 1 of 11
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When should the nurse conduct an Assessment of Immediate Safety?
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- After the screening questions and if the nurse suspects that the patient is in immediate dangerThe nurse should assess the patient for immediate safety after the screening questions and if the nurse suspects the patient is in immediate danger.
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- With every patientThe nurse should screen every patient for domestic and family violence but should assess for immediate safety only if the screening is positive or the nurse suspects the patient is in immediate danger.
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- NeverThe nurse should assess the patient for immediate safety after the screening questions and if the nurse suspects the patient is in immediate danger.
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- Before the screening questions and if the nurse suspects that the patient is in immediate dangerThe nurse should assess the patient for immediate safety after the screening questions and if the nurse suspects the patient is in immediate danger.
Question 2 of 11
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For initial screening of domestic and family violence, the nurse should ask which questions?
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- “Have you been physically injured (hit, kicked, punched) by someone in your home in the last year?”For initial screening of domestic and family violence, the nurse should ask about physical injury in the last year.
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- “Do you feel unsafe in your current relationship with your partner?”For initial screening of domestic and family violence, the nurse should ask if the patient feels unsafe in their current relationship.
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- “Are you fearful of an individual with whom you have previously had a relationship?”For initial screening of domestic and family violence, the nurse should ask if the patient is fearful of someone from a previous relationship.
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- “Has your partner ever destroyed things that you valued?”The nurse should ask this question as a follow-up question, but not for initial screening.
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- “Has your partner ever threatened or abused your children?”The nurse should ask this question as a follow-up question, but not for initial screening.
Question 3 of 11
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In assessing for immediate safety, the nurse should ask which questions?
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- “Is your partner at the health facility now?”As part of an assessment of immediate safety, the nurse should ask if the partner is currently at the health facility.
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- “Do you want to (or have to) go home with your partner?”As part of an assessment of immediate safety, the nurse should ask if the patient wants to or has to go home with the partner.
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- “Have you noticed any triggers for your partner’s behavior?”The nurse should ask questions that focus on the immediate safety of the patient, not about behavior patterns.
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- “Has your partner used weapons, alcohol, or drugs?”As part of an assessment of immediate safety, the nurse should ask if the partner has used weapons, drugs, or alcohol.
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- “Has the violence gotten worse or is it getting scarier?”As part of an assessment of immediate safety, the nurse should ask if the violence has gotten worse or is getting scarier.
Question 4 of 11
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When assessing for domestic and family violence, which actions should the nurse perform?
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- Make assumptions based on a single piece of evidence.It is important for the nurse not to make assumptions based on one single piece of evidence.
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- Look for injuries.It is important for the nurse to look for injuries when assessing for domestic and family violence.
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- Assess the behavior of the patient and the person accompanying him or her.It is important for the nurse to assess the behavior of the patient and of the person accompanying the patient when assessing for domestic and family violence.
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- Assess for general signs and symptoms of distress.It is important for the nurse to assess for general signs and symptoms of distress when assessing for domestic and family violence.
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- Allow the family member to stay in the room to support the patient.It is important to give the patient an opportunity to express concerns without a family member present.
Question 5 of 11
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If a patient exhibits general signs or symptoms of distress, the nurse should ask the patient about which of the following?
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- Stress in the patient’s lifeIf a patient exhibits general signs or symptoms of distress, the nurse should ask the patient about stresses in the patient’s life.
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- ViolenceIf a patient exhibits general signs or symptoms of distress, the nurse should ask the patient about violence.
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- Religious preferencesWhile the nurse may want to assess for support system, specific religious preferences are irrelevant.
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- Depression or anxietyIf a patient exhibits general signs or symptoms of distress, the nurse should ask the patient about depression or anxiety.
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- Alcohol or drug abuseIf a patient exhibits general signs or symptoms of distress, the nurse should ask the patient about alcohol or drug abuse.
Question 6 of 11
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If injuries are found upon assessment, which questions and statements should the nurse use to further assess the situation?
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- “Who did this to you? They are going to be in big trouble.”The nurse should conduct the assessment in a calm nonjudgmental manner and a way that does not pressure the patient.
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- “In my experience, this type of injury is sometimes caused by other people. Is anyone hurting you or frightening you?”The nurse should conduct the assessment in a calm nonjudgmental manner. The patient should not feel accused or attacked. Give the patient room to talk openly.
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- “How often has your partner victimized you?”The nurse should avoid the term “victim.”
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- “Are you lying about how his happened?”The nurse should conduct the assessment in a calm nonjudgmental manner. The patient should not feel accused or attacked. The nurse should allow the patient to discuss the subject in their own way and in their own time.
Question 7 of 11
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Which findings could the nurse expect to see on assessment of the neck when a patient reports being strangled?
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- Conjunctival petechiaeConjunctival petechiae may be present when a patient is strangled, but the nurse would see this on assessment of the eyes, not of the neck.
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- Ligature marksThe nurse could expect to find ligature marks on the assessment of the neck on a patient who has been strangled.
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- Thumb prints/contusionsThe nurse could expect to find thumb prints or contusions on the assessment of the neck on a patient who has been strangled.
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- Scratches/abrasionsThe nurse could expect to find scratches or abrasions on the assessment of the neck on a patient who has been strangled.
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- Hyoid bone fractureThe nurse could expect to find hyoid bone fracture on the assessment of the neck on a patient who has been strangled.
Question 8 of 11
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Bite marks may appear as which of the following?
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- Distinct tooth marksBite marks may appear as distinct tooth marks.
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- ErosionsBite marks do not present as erosions. Erosions might be consistent with a burn injury.
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- Contused abrasionsBite marks may appear as contused abrasions.
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- Nonspecific semicircular contusionsBite marks may appear as nonspecific semicircular contusions.
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- AbrasionsBite marks may appear as abrasions.
Question 9 of 11
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What action should the nurse perform to photograph the patient’s injuries?
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- Obtain consent after photographing.The nurse must obtain consent before, not after, photographing a patient’s injuries.
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- Obtain consent before photographing.The nurse must obtain consent before photographing a patient’s injuries.
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- Give a copy of the photographs to the patient.The nurse should not give a copy of the photographs to the patient because they are a part of the medical legal documentation.
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- Do not worry about consent because it is part of assessment.The nurse must obtain consent before photographing a patient’s injuries.
Question 10 of 11
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Which subjective data should the nurse document related to a burn injury?
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- BlistersBlisters observed by the nurse should be documented as objective data related to a burn injury.
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- RednessRedness observed by the nurse should be documented as objective related to burning.
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- Patient’s account of what happenedThe patient’s account of what happened should be documented as subjective data related to a burn injury.
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- Cigarette burn marksCigarette burn marks observed by the nurse should be documented as objective data related to a burn injury.
Question 11 of 11
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Which objective data should the nurse document related to a strangulation injury?
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- Detailed account of what happened in the patient’s own wordsA detailed account of what happened in the patient’s own words should be documented as subjective data related to a strangulation injury.
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- Ligature marksLigature marks observed by the nurse should be documented as objective data related to a strangulation injury.
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- Hyoid bone fractureHyoid bone fracture noted by the nurse should be documented as objective data related to a strangulation injury.
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- Conjunctival petechiaeConjunctival petechiae observed by the nurse should be documented as objective data related to a strangulation injury.
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- Pain and difficulty swallowingAlthough the nurse should document both pain and difficulty swallowing, these are part of the subjective data related to a strangulation injury.