A 28-year-old woman is referred to the PMHNP for persistent insomnia and depression after being treated in the emergency department of her local hospital for headaches, stomach pain, and various other physical complaints five times in the past 6 months. Which findings on the mental status exam would lead the PMHNP to suspect intimate partner violence?
She is hyperactive, with flight of ideas and rapid speech.
She is withdrawn, frightened, and hypersensitive to touch.
She is defensive and angry.
She is disorganized in her thinking and her mood is labile.
The Correct Answer is B
Choice A reason: Hyperactivity, flight of ideas, and rapid speech are more indicative of manic or hypomanic states. These symptoms are not typically associated with intimate partner violence.
Choice B reason: Withdrawal, fearfulness, and hypersensitivity to touch are classic signs of trauma and abuse. These behaviors may reflect hypervigilance, fear of physical contact, and emotional distress, all of which are consistent with a history of intimate partner violence.
Choice C reason: Defensiveness and anger may be present in various psychiatric conditions, including personality disorders or trauma responses. However, they are not as specific or telling as the signs in choice B.
Choice D reason: Disorganized thinking and labile mood may suggest psychosis or mood disorders but are not specific indicators of intimate partner violence. They lack the trauma-related behavioral cues seen in choice B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect and perpetuates a harmful myth. Asking directly about suicidal thoughts does not increase risk; instead, it opens a pathway for support and intervention. Limiting the question to self-harm also misses the broader scope of suicidal ideation.
Choice B reason: This response is misleading. There is no evidence that asking about suicide increases risk, even among those who have previously attempted. In fact, such questions can be protective by facilitating early identification and treatment.
Choice C reason: This is the evidence-based response. Research consistently shows that asking individuals—whether at risk or not—about suicidal thoughts does not increase suicidal ideation or behavior. It can reduce stigma and encourage help-seeking, making it a critical component of suicide prevention efforts.
Choice D reason: Avoiding direct questions and relying solely on third-party reports can delay identification and intervention. Direct communication with the student is essential for accurate assessment and timely support.
Correct Answer is B
Explanation
Choice A reason: Beneficence refers to actions that promote the well-being of others. It involves doing good and preventing harm, but it does not specifically address the concept of equal treatment or fairness across individuals.
Choice B reason: Justice is the ethical principle that emphasizes fairness and equality. In nursing, justice requires that care be provided impartially, without discrimination based on age, gender, socioeconomic status, ethnicity, or other factors. It ensures that all patients are treated with equal respect and dignity, making it the most appropriate answer to this question.
Choice C reason: Respect is a foundational value in nursing ethics, particularly in honoring patient autonomy and dignity. However, it is not the principle that specifically mandates equal treatment across all individuals. Justice more directly addresses equality.
Choice D reason: Fidelity refers to faithfulness and loyalty, particularly in keeping promises and maintaining trust with patients. While it is essential to ethical nursing practice, it does not encompass the idea of equal respect for all individuals.
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