Question 1

A nurse is caring for an older adult client who reports that her caregiver “sometimes forgets to give me food” and she appears dehydrated and unkempt. Which initial nursing action is MOST appropriate?

Accepted Answer

Answer reason: Failing to provide adequate food, hydration, and hygiene is a form of neglect that threatens client safety. Mandatory reporting laws require nurses to document objective findings and immediately report suspected neglect to protective services.

Question 2

A school nurse evaluates a child who flinches during assessment and has multiple bruises in different stages of healing. He states, “Sometimes my dad gets angry.” What is the nurse’s BEST response?

Accepted Answer

Answer reason: Open-ended, non-leading questions help the child describe the situation in their own words while maintaining therapeutic communication. Mandatory reporting follows after gathering objective, unbiased information.

Question 3

A nurse in the emergency department treats a client whose partner refuses to leave the room and answers all questions for the client. The client avoids eye contact and has grip-shaped marks on her arms. What is the PRIORITY nursing action?

Accepted Answer

Answer reason: The nurse must ensure private assessment when intimate partner violence is suspected. Separating the partner ensures client safety, allows honest disclosure, and supports accurate documentation.

Question 4

A home health nurse observes a caregiver shouting at a client with dementia, calling him “useless” and threatening to withhold dinner. What action should the nurse take FIRST?

Accepted Answer

Answer reason: Threats, verbal intimidation, and withholding basic needs constitute emotional abuse and neglect. Nurses are mandated reporters and must report immediately—waiting for recurrence further endangers the client.

Question 5

A nurse in the emergency department is caring for an older adult who presents with multiple bruises in various stages of healing. Which finding MOST strongly suggests elder abuse rather than accidental injury?

Accepted Answer

Answer reason: A controlling caregiver who prevents private communication is a key red flag for abuse, as it may indicate intimidation, coercion, or concealment of harm. Multiple bruises combined with restricted client communication strongly suggest non-accidental injury.

Question 6

A school nurse suspects child neglect after assessing a student. Which observation BEST supports this concern?

Accepted Answer

Answer reason: Persistent poor hygiene and inadequate clothing indicate failure to meet basic physical needs, which is a hallmark of neglect. These findings reflect ongoing caregiver omission rather than developmental or social variation.

Question 7

A nurse is caring for a hospitalized adult who quietly states, “I’m afraid to go home.” Which action should the nurse take FIRST?

Accepted Answer

Answer reason: The nurse’s priority is to ensure client safety by conducting a private, focused assessment to determine the presence and immediacy of abuse. This step guides appropriate reporting and intervention without increasing risk.

Question 8

A nurse is assessing a child in the outpatient clinic. Which finding is MOST concerning for physical abuse?

Accepted Answer

Answer reason: Patterned injuries strongly suggest inflicted trauma rather than accidental injury. Marks resembling objects or handprints are classic indicators of physical abuse and require immediate further assessment and reporting.

Question 9

A nurse is conducting a home health visit for an older adult. Which situation MOST strongly indicates possible financial exploitation?

Accepted Answer

Answer reason: Unexplained financial loss in a dependent or vulnerable adult is a key indicator of financial exploitation. This finding warrants further assessment and possible reporting to protective services.

Question 10

A nurse suspects intimate partner violence during a prenatal visit. Which assessment finding BEST supports this concern?

Accepted Answer

Answer reason: Fearful behavior, anxiety, and avoidance when discussing the home environment are common behavioral indicators of intimate partner violence. These cues warrant a private, focused safety assessment.

Question 11

A nurse in the emergency department is caring for a preschool-aged child with a fractured arm. Which caregiver statement MOST raises concern for possible abuse?

Accepted Answer

Answer reason: Vague, inconsistent, or evasive explanations for significant injuries are a classic red flag for abuse. Lack of a clear, developmentally appropriate mechanism raises concern for non-accidental trauma.

Question 12

A nurse suspects neglect in a hospitalized adult with cognitive impairment. Which finding BEST supports this suspicion?

Accepted Answer

Answer reason: Malnutrition and untreated pressure injuries indicate failure to meet basic physical needs over time. These findings reflect caregiver omission rather than disease progression alone.

Question 13

A nurse is caring for a client who reports intimate partner violence. Which nursing action is MOST appropriate to promote the client’s safety?

Accepted Answer

Answer reason: Offering resources and safety options supports autonomy while prioritizing protection. Immediate confrontation or forced actions may increase risk and are not client-centered.

Question 14

Nurses must report suspected child abuse?

Accepted Answer

Answer reason: True Nurses are mandated reporters in most jurisdictions and are legally required to report suspected (not proven) child abuse to the appropriate authorities. The nurse’s role is to recognize and report reasonable suspicion based on assessment findings and statements, not to investigate or determine guilt. Reporting helps protect the child and initiates formal evaluation and safety planning per law and institutional policy.

Question 15

The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has not much money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse would suspect that this child is?

Accepted Answer

Answer reason: The findings suggest failure to meet basic needs (hygiene, adequate clothing/food) and lack of appropriate supervision (allowed to stay out until midnight). While poverty can contribute to inadequate resources, the pattern here emphasizes caregiver omission of essential care and supervision, which is consistent with neglect. Orphan status and parental IQ are not supported by the scenario and are not sufficient explanations for the described risks.

Question 16

According to the social-interactional perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and?

Accepted Answer

Answer reason: A. The presence of a family crisis A social-interactional framework highlights how stressful environmental pressures interact with caregiver and child factors to increase the likelihood of abuse or neglect. A family crisis (e.g., job loss, divorce, acute illness) can overwhelm coping resources and increase conflict, impulsivity, and reduced supervision, thereby raising risk. The other options do not represent the broad “environment/society” domain used in this risk model and are not standardly cited as one of the four interacting categories.

Question 17

Which of the following is an example of emotional abuse?

Accepted Answer

Answer reason: Threats are a direct method of control and intimidation and therefore fit the definition of emotional abuse. Physical striking is classified as physical abuse, while leaving someone soiled is a form of neglect related to unmet basic care needs. Although ignoring/isolating can also be emotionally abusive, threats are the clearest, most unambiguous example among the choices.

Question 18

Which of the following is an example of emotional neglect?

Accepted Answer

Answer reason: Social withdrawal imposed by a caregiver and lack of engagement undermine dignity, safety, and emotional security, fitting neglect rather than an overt act of violence. Physical striking is physical abuse, and threatening language is emotional/psychological abuse rather than neglect. Leaving a patient soiled for hours reflects physical neglect of basic care needs (hygiene and skin integrity), not primarily emotional neglect.

Question 19

Which of the following screening tools have been found to have a high diagnostic accuracy for screening for intimate partner violence?

Accepted Answer

Answer reason: HITS, HARK, and STaT are all commonly cited instruments with evidence supporting useful diagnostic accuracy in clinical settings. Because each listed tool is recognized and studied for IPV screening performance, the best choice is the inclusive option. A single-tool option would be incomplete because the question asks which tools have been found to have high diagnostic accuracy, not which single tool is best.

Question 20

Physical bullying, among school aged children, threatens which of Maslow's needs?

Accepted Answer

Answer reason: Physical bullying can cause injury and pain that interfere with meeting basic physical needs and normal functioning. It also directly undermines safety needs by creating fear and risk of harm in the school environment. In addition, it damages love/belonging through peer rejection, isolation, and impaired relationships, so the most complete choice includes all listed needs.

Question 21

Which behavioral characteristic describes the domestic abuser?

Accepted Answer

Answer reason: Low self-esteem is a well-described psychosocial trait associated with abusive dynamics and helps explain the need to dominate a partner to offset internal feelings of inadequacy. Alcohol use may be present, but it is not a defining behavioral characteristic and does not explain abuse on its own. The other options are inconsistent with typical profiles (e.g., abusers often have low frustration tolerance rather than high).

Question 22

Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by?

Accepted Answer

Answer reason: In this phase, the abuser often shows remorse, apologizes, and may temporarily behave in a caring/helpful way to reduce the chance of consequences and to keep the partner from leaving. Assisting with medical care can be part of this reconciliation pattern and does not indicate that the violence risk has resolved. Minimization is also a known behavior, but the question asks for the response immediately following the incident, which most classically aligns with the remorseful reconciliation behavior.

Question 23

One reason that domestic violence remains extensively undetected is?

Accepted Answer

Answer reason: These vague presentations (e.g., chronic pain, headaches, anxiety, sleep problems) can lead clinicians to treat isolated symptoms without uncovering the underlying pattern of coercion and injury. This option directly explains why detection is low despite healthcare contact. In contrast, many victims do seek care for injuries or stress-related symptoms, but the key barrier is that the complaints may not clearly signal abuse unless screening and assessment are intentional. Recognizing recurrent, inconsistent, or unexplained minor complaints should prompt private, trauma-informed screening and safety assessment.

Question 24

A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?

Accepted Answer

Answer reason: Separating the client from accompanying individuals is the immediate priority because the companion may be the abuser and their presence can suppress disclosure and increase risk. Once privacy is ensured, the nurse can use trauma-informed, nonjudgmental questions to assess injuries, safety, and immediate danger. Documentation steps (e.g., photographing injuries) and detailed history about prior injuries are important but are not the first action if the client cannot be interviewed safely.

Question 25

A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

Accepted Answer

Answer reason: A request for time away can trigger abandonment fears and escalation, increasing anger, intimidation, and risk of further harm. This response pattern fits the cycle of violence, in which attempts to leave or set boundaries are high-risk periods for retaliation. The more benign responses (acceptance, relief, sudden insight with counseling) are less consistent with typical batterer behavior and do not reflect the heightened danger associated with separation.

Question 26

Which statement by the client during the initial assessment in the emergency department is most indicative for suspected domestic violence?

Accepted Answer

Answer reason: " A core indicator of intimate partner violence is the cyclical pattern of abuse with repeated attempts to leave followed by returning due to fear, threats, financial dependence, isolation, or trauma bonding. This statement reflects that classic cycle and signals ongoing risk and difficulty achieving safety despite prior efforts. It suggests the need for immediate safety assessment, validation, and connection to resources rather than assuming the situation is resolved. In contrast, being newly married or planning to leave soon does not specifically indicate abuse dynamics and is less predictive than the repeated leave-return pattern.

Question 27

A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first?

Accepted Answer

Answer reason: This includes asking focused, nonleading questions about who, what, when, where, and any injuries or threats, while ensuring the client is safe and supported. Directly calling police may be appropriate after clarifying urgency and immediate danger, but it is not the first step without assessment. Documentation and notifying the manager are required steps, but they follow initial data collection and safety evaluation.

Question 28

7 A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?

Accepted Answer

Answer reason: Victims may believe that changing their behavior or being “better” would prevent assault, which reinforces the abuser’s control and reduces help-seeking. This differs from helplessness, which is more about perceived inability to change the situation rather than accepting fault for the violence. Identifying this feeling guides nursing care toward validation, safety planning, and referral to appropriate support resources.

Question 29

A victim of domestic violence states to the nurse, “If only I could change and be how my companion wants me to be, I know things would be different.” Which would be the best response by the nurse?

Accepted Answer

Answer reason: A key therapeutic principle in intimate partner violence is to remove blame from the victim and clearly identify the perpetrator’s responsibility for the abuse. This response directly reframes the client’s self-blaming statement and reinforces that abuse is driven by the batterer’s choice and internal dynamics, which supports safety planning and empowerment. Option C is harmful because it implies the victim may have provoked the violence, reinforcing guilt and decreasing likelihood of disclosure. Options A and B minimize or normalize abuse and suggest it can be explained or fixed by the victim, which is unsafe and nontherapeutic.

Question 30

The pediatric nurse assesses multiple clients. Which of the following clients should the nurse investigate further for potential child abuse?

Accepted Answer

Answer reason: Abuse screening relies on matching the injury pattern and developmental capabilities to the history provided. At 7 months, infants typically cannot climb to a sink/countertop, making the mechanism inconsistent and raising concern for inflicted injury or unsafe supervision. Contact burns on the palms can occur with forced contact or defensive reflexes and warrant careful assessment of burn pattern, depth, and symmetry. By contrast, option A is consistent with a common viral exanthem pattern, and option B describes a likely benign congenital dermal melanocytosis; option C is a plausible mechanism in an older child with typical play injuries.

Question 31

The nurse is assessing a pediatric client with injuries suggestive of possible child abuse. Which of the following would be an appropriate response for the nurse to make to the client’s parent?

Accepted Answer

Answer reason: ” In suspected abuse, the nurse should use a calm, neutral, open-ended, nonjudgmental approach to elicit information and reduce defensiveness. This phrasing explores discipline methods without accusing or leading the parent, which supports accurate assessment and documentation. Directly accusing the caregiver or using loaded language can escalate conflict and decrease the likelihood of truthful disclosure. Mandatory reporting is required when abuse is suspected, but communicating it as an immediate threat is not the best initial therapeutic response compared with further neutral assessment questions.

Question 32

The nurse is talking with a client in the emergency department who is the victim of intimate partner violence. The client states, "My partner just gets mad sometimes, he's not a bad man. I can't leave him." Which of the following would be an appropriate response for the nurse to make?

Accepted Answer

Answer reason: " In intimate partner violence, the nurse’s priority is to provide a nonjudgmental, supportive response that respects the client’s autonomy while promoting safety and access to help. Offering resources (e.g., shelters, hotlines, social work, safety planning) empowers the client and keeps the therapeutic relationship open, which is crucial when the client is ambivalent or not ready to leave. Directives or threats can increase shame, defensiveness, and may escalate danger if the partner becomes aware of the disclosure. The other statements are judgmental or coercive and do not focus on immediate supportive intervention and linkage to services.

Question 33

The nurse working in a long-term care facility knows that elder abuse most often consists of?

Accepted Answer

Answer reason: Elder mistreatment most commonly presents as failure to meet basic needs rather than overt violence. In long-term care and community settings, this often shows up as inadequate nutrition/hydration, poor hygiene, missed medications, untreated medical problems, or unsafe living conditions due to omission of care. These deficits can occur intentionally or from caregiver burnout or lack of resources, but they still constitute abuse and require reporting and intervention. Physical and sexual abuse are serious but occur less frequently than neglect, and financial exploitation is common but not the most frequent overall.

Question 34

Which is a familial factor that most accurately places a family at risk for child abuse and neglect?

Accepted Answer

Answer reason: Social isolation is a key family-level risk factor for child maltreatment because it reduces supportive monitoring, practical help, and emotional coping resources for caregivers. Without extended family, community ties, or access to services, caregiver frustration and ineffective coping are more likely to escalate into neglect or abusive responses. Severe caregiver stress is important but is less specific as a “familial” context factor because stress can exist even with strong supports that buffer risk. A difficult child temperament is a child factor (not familial), and having no history of abuse does not increase risk.

Question 35

Which factor most accurately reflects characteristics of the child that place families at risk for child abuse and neglect?

Accepted Answer

Answer reason: Child-related risk factors for maltreatment include traits that increase caregiver stress and reduce effective bonding, such as a “difficult” temperament with frequent crying, irritability, or poor consolability. These characteristics can heighten frustration in caregivers with limited coping skills and make harsh or neglectful responses more likely. By contrast, social isolation and beliefs about physical punishment are primarily family/parent factors rather than child characteristics. A healthy child is generally a protective, not risk, characteristic.

Question 36

The nurse is reviewing the medical records of children who have been abused. Which main common characteristic of parents who abuse children is the nurse most likely to identify?

Accepted Answer

Answer reason: Social isolation reduces access to practical help (respite care, advice, financial/community assistance) and increases the likelihood that escalating conflict or frustration goes unrecognized and unaddressed. This factor is more consistently identified across abuse/neglect assessments than a specific psychiatric diagnosis, which is not present in most abusing caregivers and is not predictive by itself. Age over 40 is not a recognized primary risk marker for abuse, and while violence can occur, the broader, commonly cited pattern in family-risk screening is isolation and poor support systems.

Question 37

Primary prevention of domestic abuse involves?

Accepted Answer

Answer reason: Primary prevention aims to stop violence before it occurs by reducing risk factors and building protective skills and supports. Enhancing coping, resilience, and stress-management resources for individuals and families targets upstream contributors (e.g., poor coping, high stress, limited support) that can increase the likelihood of abuse. In contrast, identifying at-risk families is more consistent with secondary prevention (screening/risk detection), and intervening to stop violence reflects tertiary prevention after abuse has begun. The correct choice best matches the goal of preventing initial occurrence through strengthening and education at a broad level.

Question 38

Three sets of factors place families at risk for child abuse and neglect. Parental risk factors that place families at risk for child abuse and neglect include?

Accepted Answer

Answer reason: Intergenerational transmission of violence is a well-established risk factor for perpetrating child maltreatment, especially when a caregiver has unresolved trauma, impaired coping skills, or maladaptive learned parenting behaviors. A parental history of being abused or neglected increases the likelihood of harsh discipline, poor attachment, and reduced stress tolerance when faced with normal child behaviors. In contrast, child behavior problems are considered child-related factors rather than parental factors, and strong community friendships are generally protective through social support. Belief in punitive approaches may be a risk, but prior personal victimization is a more direct and consistently cited parental risk factor for abuse/neglect.

Question 39

The nurse is collecting information from the family in which Munchausen Syndrome by Proxy (MSP) is suspected. Which finding should the nurse expect?

Accepted Answer

Answer reason: MSP (factitious disorder imposed on another) commonly involves a caregiver who appears devoted, attentive, and highly involved with the child’s care while fabricating or inducing illness. This “strong bond” presentation can mislead staff because the caregiver seems cooperative and concerned, often seeking attention through the child’s medical condition. In contrast, the perpetrator is more often the mother/caregiver rather than the father, and the caregiver frequently demonstrates substantial medical knowledge or comfort in healthcare settings. The child typically cannot reliably explain what is happening due to young age, coercion, or lack of awareness of the induced/fabricated nature of symptoms.

Question 40

A nurse suspects that the laboring client may have been physically abused by her male partner. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: The priority nursing principle in suspected intimate partner violence is to support the client’s safety, privacy, and access to resources without escalating risk. Coordinating care with the interprofessional team enables appropriate assessment, documentation, safety planning, and linkage to advocacy/social services consistent with institutional and legal requirements. Confronting the partner or questioning the client in front of him can increase danger, inhibit disclosure, and worsen control dynamics. Security is reserved for immediate threats or violent behavior; suspicion alone calls first for a safe, confidential, resource-oriented response and referral pathway.

Question 41

The nurse is assessing for 2- to 3-year-old children presenting with burn injuries. Which injuries would least likely trigger the need for further follow- up for potential child abuse and mandatory reporting?

Accepted Answer

Answer reason: Accidental burns in toddlers commonly occur from brief spills or splashes of hot liquids that hit exposed anterior areas during normal exploration or when a caregiver is cooking or holding a hot beverage. This pattern tends to be irregular in depth and distribution rather than sharply demarcated or symmetric. In contrast, circumferential burns of the wrists suggest forced immersion or restraint, and round burns on the soles are classic for intentional contact/inflicted injury. Dependent, symmetric scalding on feet/legs can also indicate forced immersion (eg, “stocking” distribution), which appropriately raises concern for abuse.

Question 42

A woman presents to the emergency department with a fractured arm. Her husband is constantly by her side, and the woman appears anxious. What action should the nurse initially take?

Accepted Answer

Answer reason: Immediate safety and accurate assessment for intimate partner violence require interviewing the patient privately, away from any potential perpetrator or controlling companion. Creating a brief, plausible separation (e.g., restroom or exam area) allows screening questions to be asked without coercion and supports disclosure. Asking about safety “during triage” is not appropriate if the partner is present because it can escalate risk and invalidate the screening. Providing a pamphlet is supportive but not the first priority because the nurse must first establish privacy, assess risk, and determine immediate protection needs.

Question 43

A nurse working in a Planned Parenthood clinic routinely asks clients about experiencing possible domestic violence. The advantage of this line of questioning is that it?

Accepted Answer

Answer reason: Routine, universal screening for intimate partner violence improves patient safety by identifying risk early and enabling timely safety planning and referral to supportive resources. Normalizing the questions can reduce stigma and increase disclosure by signaling that the clinic is a safe place to discuss abuse. The goal is not to force a confession or guarantee “truth,” but to open a path to assessment, documentation, and interventions (e.g., shelters, crisis support, legal resources) that reduce harm. Options implying alienation or police-oriented aims are inconsistent with therapeutic, patient-centered screening and can deter disclosure and follow-up care.

Question 44

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes many ecchymotic areas in various stages of healing on his body. Which action should the nurse perform first?

Accepted Answer

Answer reason: Unexplained ecchymoses in different stages of healing raise concern for possible elder abuse, and the nurse’s first priority is focused assessment and safety-oriented data collection. Asking the client for an explanation (using therapeutic, nonjudgmental questions and assessing consistency with the physical findings) helps determine immediacy of risk and guides next actions. Notification and reporting steps are important but should follow initial assessment unless there is an immediate life-threatening danger. Documentation is essential, but it is not the first action when more assessment is needed to clarify the situation and protect the client.

Question 45

The older, disheveled client is admitted to the ED with hypertension, severe dehydration, and malnourishment. During the admission interview, the daughter notes that she and her husband, who is temporarily out of work, have been living with the client. Which nursing action is most important?

Accepted Answer

Answer reason: Assessment is the priority when abuse/neglect is suspected because accurate, first-hand information guides immediate safety actions and required reporting. Interviewing the older adult privately reduces coercion and allows the nurse to evaluate for neglect, exploitation, and fear, as well as assess decision-making capacity and immediate safety needs. Reporting may be required once reasonable suspicion exists, but the most important initial nursing action during the interview is to obtain unbiased information directly from the client. Options that rely on the daughter’s account risk missing abuse dynamics and may further compromise the client’s ability to disclose.

Question 46

The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman’s torn and soiled clothing. What is the nurse’s best response?

Accepted Answer

Answer reason: “These may be needed by the police. I will remove them and place in separate paper bags.” In suspected sexual assault, the priority is preserving forensic evidence while maintaining chain-of-custody and preventing contamination. Clothing can contain semen, blood, hair, fibers, and trace evidence, so each item should be handled minimally and stored separately. Paper bags are preferred because they allow moisture to evaporate and reduce degradation of evidence; plastic can trap moisture and promote mold, compromising samples. The other responses either risk evidence loss through disposal/handling decisions by the client in the acute phase or use inappropriate storage that can damage evidence.

Question 47

The nurse is assessing a child in the emergency department with a fractured tibia. The medical record shows the client was recently discharged for a fracture to the radius and clavicle. The nurse is suspicious for?

Accepted Answer

Answer reason:  Multiple fractures in different bones over a short time span are a classic red flag for non-accidental trauma, especially when injuries are recurrent and involve long bones and the clavicle. This presentation suggests inflicted injury rather than a single isolated accident, prompting suspicion for physical abuse and the need for mandated reporting and a safety-focused assessment. Neglect more commonly reflects failure to provide basic needs or supervision rather than a pattern of repeated fractures across encounters. Osteosarcoma would more typically present with localized bone pain/swelling and may lead to a pathologic fracture, but it would not best explain several recent fractures at different sites.

Question 48

Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?

Accepted Answer

Answer reason: The other statements describe common dynamics seen in abusive relationships, including controlling behaviors, jealousy, and use of fear/intimidation to maintain power. Teaching should emphasize that risk exists in any family and that assessment should be universal and based on behavior patterns and safety indicators. Correcting this stereotype supports unbiased identification, prevention, and referral.

Question 49

The nurse plans a staff development conference about intimate partner violence (IPV). Which of the following statements, if made by a participant, would indicate a correct understanding of the conference?

Accepted Answer

Answer reason: A core principle in IPV education is that IPV affects all genders, and disclosure is often delayed due to shame, fear, and social stigma. This statement reflects a recognized barrier to reporting among male survivors, supporting accurate staff understanding for screening and response. Option A is incorrect because best practice is routine/universal screening when safe and appropriate rather than screening only “select” individuals. Option B is unsafe because nurses cannot promise absolute confidentiality due to mandatory reporting requirements in some jurisdictions and duty to protect when imminent harm is present; instead, confidentiality limits must be explained. Option D is inaccurate because IPV injuries are often hidden (e.g., trunk, breasts, abdomen) and may not be “usually” obvious on the face and hands.

Question 50

The nurse is performing an assessment for a client who is pregnant in her third trimester. The nurse assessed several bruises in various stages of healing on her arms and upper back. The nurse plans on assessing the client for?

Accepted Answer

Answer reason: Bruises in various stages of healing, particularly on the upper arms and back, are a classic injury pattern suggesting repeated trauma rather than an isolated accidental event. Pregnancy increases risk for domestic abuse, so routine, private screening is a safety priority to protect both the client and fetus. This finding is not explained by iron-deficiency anemia, which causes fatigue and pallor rather than patterned bruising, and polycythemia vera is unlikely in pregnancy and does not present primarily with bruises. Identifying possible abuse prompts further assessment, documentation, and referral to appropriate safety resources.

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