A nurse in an emergency department is caring for a client who recently experienced partner violence.
The nurse is reviewing the client’s medical record at discharge. For each finding, specify whether the finding indicates a potential improvement in or a worsening of the client’s physical or psychological status.
Client states that the partner will not be violent in the future.
Client agrees to an appointment with a social worker.
Client’s reported pain level of the left wrist.
Client requests help developing a safety plan.
Client claims responsibility for the physical altercation.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Choice A Reason: The belief that a partner will not be violent in the future can be a form of denial or wishful thinking, especially without any evidence of change or intervention. It is not uncommon for individuals in abusive relationships to hope for change, but without concrete actions, such as therapy or other interventions, this hope does not indicate an improvement in the client’s situation.
Choice B Reason: Agreeing to an appointment with a social worker is a positive step towards addressing the situation and seeking help. Social workers can provide support, resources, and guidance, which can be crucial for someone experiencing partner violence. This choice indicates a potential improvement in the client’s psychological status as it shows a willingness to engage with support services.
Choice C Reason: A decrease in reported pain levels can indicate physical improvement. Pain scales are subjective but provide a measure of the client’s comfort and can reflect healing or the effectiveness of pain management strategies.
Choice D Reason: Requesting help to develop a safety plan is a proactive step in ensuring personal safety and preparing for potential future incidents of violence. It shows the client’s awareness of the risks and a desire to protect themselves, which is a positive indicator of psychological improvement.
Choice E Reason: While claiming responsibility for the physical altercation may seem negative, it can also be seen as the client’s attempt to make sense of the situation. It is important to note that responsibility for violence lies with the perpetrator, not the victim. However, recognizing the dynamics of the relationship and the events leading up to the violence can be part of the healing process and taking control of one’s life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.
Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.
Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.
Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.
Correct Answer is C
Explanation
Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.
Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.
Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.
Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.
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