A nurse is assisting with the care of a 45-year-old female client who is in the emergency department.

Exhibits

Click to highlight the findings from the nurses’ notes that indicate partner violence and should be reported to the provider.

Nurses’ Notes for Highlighting:
Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. Laceration to the left cheek cleansed and covered with an adhesive bandage. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.” Client has been married for 22 years and has two children. Client works part-time and volunteers at a community center. Client is tearful, does not make eye contact, and only speaks when spoken to. Client requests not to notify their partner because they do not want them to have to miss work or worry. Client reports poor appetite and difficulty sleeping.

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.

Laceration to the left cheek cleansed and covered with an adhesive bandage.

Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing.

Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

Client has been married for 22 years and has two children.

Client works part-time and volunteers at a community center.

Client is tearful, does not make eye contact, and only speaks when spoken to.

Client requests not to notify their partner because they do not want them to have to miss work or worry.

Client reports poor appetite and difficulty sleeping.

Answer and Explanation

The Correct Answer is ["A","D","G","H","I"]

The findings that indicate possible partner violence and should be reported to the provider include:

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.
Client is tearful, does not make eye contact, and only speaks when spoken to.
Client reports poor appetite and difficulty sleeping.
Client requests not to notify their partner because they do not want them to have to miss work or worry.
Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

These signs, particularly the bruising in different healing stages, avoidance of eye contact, emotional distress, reluctance to notify the partner, and vague or inconsistent injury explanations, may indicate potential intimate partner violence. Ensuring proper screening, support, and intervention is crucial in situations like these. The client’s safety and well-being should remain a priority, and reporting these findings to the healthcare provider allows for further assessment and assistance.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Liver enzymes (such as ALT and AST) are primarily monitored for medications known to cause liver toxicity. While lithium can have various side effects, it is not typically associated with significant liver damage requiring routine monitoring of liver enzyme levels. Normal ranges for ALT are typically 7 to 55 units per liter (U/L) for men and 5 to 40 U/L for women, and for AST are typically 10 to 40 U/L for men and 9 to 32 U/L for women.

Choice B rationale

Lithium is a mood stabilizer with a narrow therapeutic range, and its levels are closely linked to sodium balance in the body. Hyponatremia (low sodium levels) can increase the risk of lithium toxicity because the kidneys reabsorb lithium in an attempt to compensate for the sodium loss. Therefore, regular monitoring of serum sodium levels is crucial to ensure lithium remains within the therapeutic range (typically 0.6 to 1.2 mEq/L for maintenance) and to prevent toxicity. Normal serum sodium levels are generally 135 to 145 mEq/L.

Choice C rationale

Uric acid levels are primarily monitored in conditions like gout or kidney disease, or as a side effect of certain medications affecting purine metabolism. Lithium does not typically have a significant impact on uric acid levels requiring routine monitoring. Normal uric acid levels are typically 3.5 to 7.2 mg/dL for men and 2.6 to 6.0 mg/dL for women.

Choice D rationale

Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. While lithium can have various effects, it is not typically associated with significant changes in ESR that would necessitate routine monitoring. Normal ESR values are generally 0 to 15 mm/hr for men and 0 to 20 mm/hr for women. .

A. Cardiac arrhythmia. B. Crohn's disease. C. Asthma. D. Renal colic.

Correct Answer is A

Explanation

Choice A rationale

Cardiac arrhythmia is a significant concern prior to electroconvulsive therapy (ECT) because ECT involves inducing a brief seizure. The physiological stress of a seizure can exacerbate pre-existing cardiac conditions, potentially leading to serious complications such as further arrhythmias or cardiac arrest. Therefore, any history of cardiac arrhythmia should be reported to the provider for careful evaluation and management before proceeding with ECT.

Choice B rationale

Crohn's disease is a chronic inflammatory bowel disease and is not a direct contraindication for ECT. While the client's overall health is considered, Crohn's disease does not pose an immediate risk of serious complications during or after the ECT procedure itself. The focus for ECT contraindications is primarily on neurological and cardiovascular conditions.

Choice C rationale

Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. While it requires careful management, asthma is not typically a direct contraindication for ECT. Precautions would be taken to ensure adequate oxygenation during the procedure, but it does not inherently increase the risk of severe complications related to the induced seizure.

Choice D rationale

Renal colic, which is pain associated with kidney stones, is an acute condition but not a direct contraindication for ECT. While the client's comfort and pain management would be important considerations, renal colic does not increase the risk of serious complications related to the seizure induced by ECT. The primary concerns for ECT are conditions that could be negatively impacted by the seizure activity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy.The nurse should notify the provider for which of the following findings?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has schizophrenia.The nurse should identify which of the following manifestations as an indication of relapse?

A nurse is receiving report on four clients at the beginning of the shift.Which of the following clients should the nurse check first?

A nurse is reviewing the treatment plan of a client who is receiving anger management therapy.Which of the following Questions should the nurse ask the client to evaluate the effectiveness of the treatment plan?

A nurse is providing information to a client about smoking cessation.Which of the following medications should the nurse include?

A nurse is assisting in the care of a client following a mastectomy.Which of the following responses by the client indicates acceptance of their altered body image?

A nurse is caring for a client who has major depressive disorder.The client tells the nurse, "I should be dead.I have been a failure.”. Which of the following responses should the nurse make?

A nurse is collecting data from a female client who has bulimia nervosa.Which of the following manifestations should the nurse expect?