A nurse is caring for a client and has suspicions of intimate partner violence based on her observations.
Which of the following is the most appropriate nursing intervention?
Ask direct Questions, while providing empathy, respect, and privacy.
Document what you think is going on in great detail in the EHR.
Ensure that all unit personnel are informed of your suspicions.
Avoid assessing for suicide risk to prevent upsetting the client.
The Correct Answer is A
Choice A rationale
Asking direct questions in a private, non-judgmental, and empathetic manner is the most appropriate initial intervention. This approach creates a safe and supportive environment for the client, promoting trust and encouraging disclosure. It respects the client's autonomy and right to privacy, which is crucial for rapport building. Documenting the findings accurately is important after the initial assessment.
Choice B rationale
Documenting what one thinks is happening without direct confirmation is speculative and could be considered unprofessional or inaccurate. Nursing documentation must be based on objective observations and verifiable client statements. While detailed documentation is important, it must be factual and non-judgmental, focusing on the client's reported experiences and physical findings rather than the nurse's assumptions or interpretations.
Choice C rationale
Disseminating information about suspected intimate partner violence to all unit personnel violates client confidentiality and can compromise the client's safety. This information should be shared only with relevant members of the healthcare team on a need-to-know basis to ensure coordinated care. Unnecessary disclosure can expose the client to further harm and breaches professional and ethical nursing standards.
Choice D rationale
Avoiding assessment for suicide risk is a serious oversight and potentially dangerous. Individuals experiencing intimate partner violence are at a significantly higher risk for suicide and mental health issues. A thorough and compassionate suicide risk assessment is a critical component of a comprehensive evaluation for any client with suspected abuse. It is a fundamental safety intervention that must be performed
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale
The statement is incorrect. While calcium and potassium are crucial electrolytes, their fluctuations are not the primary cause of dependent edema during pregnancy. The normal serum calcium level is 8.5-10.2 mg/dL, and the normal potassium level is 3.5-5.0 mEq/L. Swelling is predominantly a mechanical issue related to the growing uterus and hormonal changes, not electrolyte imbalances.
Choice B rationale
The statement is false. The swelling of the lower extremities, vulva, and rectum is not caused by changes in calcium and potassium levels. Instead, it is a multifactorial issue resulting from increased intravascular volume, venous pressure, and hormonal effects. This condition is also known as dependent edema and is a common physiological finding in pregnancy due to the weight of the uterus.
Choice C rationale
The statement is correct. As pregnancy progresses, the gravid uterus exerts increasing pressure on the inferior vena cava and pelvic veins, obstructing venous return from the lower extremities. Additionally, pregnancy-related increases in blood volume and capillary permeability contribute to fluid shifting from the intravascular space into the interstitial tissues, resulting in dependent edema.
Choice D rationale
The statement is incorrect. During a normal pregnancy, the body's blood volume actually increases by approximately 45% to meet the metabolic demands of the fetus and placenta. This increase in blood volume, coupled with hormonal changes (e.g., relaxin, estrogen), contributes to the increased fluid retention and subsequent swelling, not a decrease in blood volume
Correct Answer is C
Explanation
Choice A rationale
Providing nutritional education is a critical aspect of prenatal care, but it is not the immediate priority, especially given the patient's presentation. While folic acid supplementation is vital for preventing neural tube defects, it is a routine intervention that can be addressed after ensuring the patient's immediate safety and well-being. The patient's anxiety and withdrawn demeanor suggest a potential underlying issue that needs immediate attention before standard education is provided.
Choice B rationale
Offering genetic studies, such as chorionic villus sampling or amniocentesis, is an important component of prenatal care, but these are typically offered later in the pregnancy and are not the first priority. Genetic counseling and screening are usually discussed based on maternal age, family history, and other risk factors, and they do not address the patient's immediate psychological and social needs as evidenced by her demeanor.
Choice C rationale
Screening for intimate partner violence (IPV) and other social determinants of health is the most critical first action. The patient's withdrawn and fearful demeanor, combined with her anxiety, are significant red flags for potential abuse or other stressors. Addressing her safety and psychosocial well-being is the highest priority, as violence can have devastating effects on both maternal and fetal health. This action aligns with the principle of ensuring immediate safety before proceeding with other routine care.
Choice D rationale
Assessing for vaccination status and administering the flu vaccine are important public health measures during pregnancy. However, they are not the first priority when the patient's demeanor suggests a potential safety or mental health crisis. While the flu vaccine is recommended for pregnant women, it can be addressed after the nurse has evaluated and addressed the patient's immediate psychosocial needs, as indicated by her anxiety and withdrawn state. *.
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