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.

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Correct Answer is D

Explanation

Choice A rationale

Consuming red wine before bed, even in small amounts, can disrupt sleep architecture. While alcohol might initially induce drowsiness, it often leads to fragmented sleep later in the night as the body metabolizes it, resulting in poor sleep quality and reduced restorative sleep.

Choice B rationale

Staying in bed for prolonged periods when unable to sleep can create a negative association between the bed and wakefulness. This can increase anxiety about sleep and perpetuate insomnia. It is generally recommended to get out of bed and engage in a relaxing activity until feeling sleepy.

Choice C rationale

Exercising vigorously close to bedtime can be stimulating and raise core body temperature, making it harder to fall asleep. The body needs time to cool down for optimal sleep initiation. It is generally recommended to avoid intense exercise at least a few hours before bed.

Choice D rationale

Caffeine is a stimulant that can interfere with sleep initiation and maintenance. Limiting caffeine intake, especially in the afternoon and evening, can significantly improve sleep quality by reducing its stimulating effects on the central nervous system. Normal caffeine intake should be limited, and eliminating it closer to bedtime is beneficial for sleep.

A. "You are feeling like a failure.”. B. "I see many positive things about you.”. C. "You're not the only client who feels this way.”. D. "How can you feel that way when you have so much to live for?"

Correct Answer is A

Explanation

Choice A rationale

Reflecting the client's feeling back to them, such as "You are feeling like a failure," acknowledges their emotional state without judgment or dismissal. This therapeutic communication technique validates the client's feelings and encourages further exploration of their thoughts and emotions.

Choice B rationale

While intended to be positive, stating "I see many positive things about you" can minimize the client's current feelings and may not address the underlying reasons for their negative self-perception. It can also sound dismissive of their distress.

Choice C rationale

Saying "You're not the only client who feels this way" can minimize the client's individual experience and may make them feel that their feelings are not unique or important. It does not directly address their specific statement of wanting to be dead.

Choice D rationale

Asking "How can you feel that way when you have so much to live for?" invalidates the client's current feelings and can make them feel misunderstood or defensive. It does not address the depth of their despair and suicidal ideation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night.Which of the following recommendations should the nurse make?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

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