A nurse is assessing a client who presents with injuries and signs that may suggest intimate partner violence. Which of the following statements by the client would most likely indicate the need for further assessment and intervention?
"I have bruises from a recent sports injury."
"I'm experiencing stress from work and it's affecting my health."
"I fell down the stairs and injured my arm."
"I often feel afraid at home, but I don't want to talk about it."
The Correct Answer is D
A. Bruises from a sports injury are less likely to indicate intimate partner violence without additional context.
B. Stress from work is a general issue and does not directly suggest intimate partner violence.
C. A fall down the stairs could be an accident; however, further context is needed to assess if this is related to violence.
D. Fear at home and reluctance to discuss it could indicate underlying intimate partner violence, requiring further assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Telling the client she should leave is not supportive and may not be appropriate; decisions about leaving should be made by the client.
B. Helping the client get her partner into a treatment program is not within the nurse's immediate role and does not address the client’s immediate safety needs.
C. Helping the client to develop a safety plan and providing emergency contact information is crucial for the client’s immediate safety and is an appropriate intervention.
D. Assisting the client to explore resources such as shelters and legal protection supports her in making informed decisions and accessing necessary help.
E. Communicating acceptance of the client's decision and avoiding blame helps build trust and ensures the client feels supported in a non-judgmental environment.
Correct Answer is A
Explanation
A. Nurses are mandated reporters and must report suspicions of abuse or neglect, regardless of concrete evidence or verbal admission.
B. A verbal admission from the victim is not required; suspicions alone are sufficient to make a report.
C. While notifying a supervisor may be part of internal protocols, it is not a legal requirement for making a report.
D. Notifying the parents may not be safe or appropriate in cases of abuse, and it is not a requirement for reporting abuse or neglect.
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