A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?
"You should try to see your partner's point of view before your own.”
"Relationship difficulties are stressful and require effort to resolve.”
"We could develop a plan for how to talk about this with your partner.”
"Tell me more about the concerns that you have regarding your marriage.”
The Correct Answer is A
Choice A rationale:
This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.
Choice B rationale:
Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.
Choice C rationale:
Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.
Choice D rationale:
Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: c. Document the client's verbatim statements.
Here's why the other options are wrong:
- a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
- b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
- d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.
Documenting the client's verbatim statements is the most important initial action because:
- It preserves the client's account of the assault in their own words.
- It allows for accurate reporting and investigation.
- It can be used as evidence in legal proceedings.
Here are some supporting points:
- The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
- The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]
In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Phase IV is not a recognized phase in the cycle of battering. Typically, the cycle of battering consists of three phases: tension-building, acute battering, and honeymoon phase. Each phase has distinct characteristics.
Choice B rationale: Phase I, the tension-building phase, is characterized by increased tension, irritability, and frustration in the abuser. The victim may sense the abuser's declining tolerance for frustration, leading them to try to avoid confrontation by staying out of the abuser's way.
Choice C rationale: Phase III is the honeymoon phase, where the abuser may apologize, show remorse, and be affectionate. The victim may feel hopeful for change. However, this does not match the described behavior of increasing frustration and anger with quick apologies.
Choice D rationale: This is a duplicate of Choice B. As previously stated, Phase I, the tension-building phase, involves the buildup of tension and irritability in the abuser, leading the victim to try to stay out of the abuser's way to avoid conflict.
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