When beginning care for a victim of rape, the nurse asks the ...

[@Brianna17]

When beginning care for a victim of rape, the nurse asks the patient to talk about what happened to her. For which nursing diagnosis is the nurse using this approach?
 
  A) Anxiety related to recent rape
  B) Fear related to repeated episodes of maltreatment
  C) Disabling family coping related to recent rape of family member
  D) Risk for other-directed violence related to admitted poor self-control

Question 2

At the completion of a health interview, the nurse is concerned that a newborn is at risk for maltreatment. Which observation caused the nurse to come to this conclusion?
 
  A) Mother does not look at the baby.
  B) Mother helps the nurse loosen the baby's clothing for a physical examination.
  C) Mother explains that the husband helps with feeding the baby during the night.
  D) Mother quickly changes a dirty diaper and uses personal supplies to cleanse the child.

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Answer to Question 1

A
Feedback:
One need of any victim after a violent act is to talk about what happened because a person who can describe an incident can also begin to put a fence around or bring the event down from something terrible has happened, a situation which leaves the person with a continuing high anxiety level, to this specific thing has happened, a situation that allows the traumatic event to be examined and managed. Asking the victim to describe the incident to with an introduction such as Most people find it helps to talk about what happened to them helps the victim begin to put a fence around the incident. The nurse is not asking the patient to talk about what happened because of fear of maltreatment, disabling family coping related to the rape, or risk for violence related to poor self-control.

Answer to Question 2

A
Feedback:
The mother's inability to establish eye contact, or maintain a direct en face position with the baby, can indicate the potential for child maltreatment. Helping the nurse loosen clothing for an examination, identifying someone to help with child care, and prompt attention to the baby's needs when changing a soiled diaper indicate the mother is bonding with the child, and the child is not at risk for maltreatment.