A nurse is caring for a client who is in the emergency department.
The nurse is preparing to use a standardized screening tool to assess the client for partner violence. Click to highlight the actions the nurse should take during the assessment. To deselect an action, click on the action again.
Interview the client with another nurse present.
Ask questions in different ways until the client provides an answer.
Ask the client if they have been hit, slapped, or kicked within the past year.
Refrain from asking the client if they are afraid of their partner.
Ask the client to clarify the circumstances of their injuries.
Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them.
Inform the client that they should have fought back.
Discuss with the client the factors that precipitate violence.
Interview the client with another nurse present.
Ask questions in different ways until the client provides an answer.
Ask the client if they have been hit, slapped, or kicked within the past year.
Refrain from asking the client if they are afraid of their partner.
Ask the client to clarify the circumstances of their injuries.
Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them.
Inform the client that they should have fought back.
Discuss with the client the factors that precipitate violence.
The Correct Answer is ["C","E","H"]
Rationale for correct choices:
- Ask the client if they have been hit, slapped, or kicked within the past year: This question is specific and nonjudgmental, helping the client disclose abusive behaviors without feeling pressured. It's important for identifying signs of abuse that may not be immediately obvious.
- Ask the client to clarify the circumstances of their injuries: Clarifying the circumstances of the injuries helps the nurse assess the situation and detect any discrepancies in the explanation that may suggest abuse. It can also guide the next steps in care and safety planning.
- Discuss with the client the factors that precipitate violence: Identifying triggers and patterns of violence empowers the client to recognize and avoid dangerous situations, and to plan for their safety moving forward.
Rationale for incorrect choices:
- Interview the client with another nurse present: The primary goal during is to establish a private and trusting environment where the client feels safe to disclose. The presence of another person can make a client feel less comfortable and less likely to speak openly about sensitive issues like intimate partner violence.
- Ask questions in different ways until the client provides an answer: Repeating or rephrasing questions multiple times could make the client feel pressured or coerced, which may hinder trust and open communication. It’s important to respect their pace and comfort level.
- Refrain from asking the client if they are afraid of their partner: Fear of the partner is a crucial indicator of abuse, and not asking about it may prevent the client from disclosing important information. Acknowledging fear helps assess the level of risk and urgency.
- Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them: While empathy is important, making value judgments about the abuser can undermine the client's trust, making them feel judged or unsupported in their decisions.
- Inform the client that they should have fought back: Telling the client what they "should have done" may inadvertently place blame on them and discourage further disclosures. It’s vital to maintain a supportive, nonjudgmental stance to ensure the client feels safe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Staying with the client for 15 minutes following meals is insufficient. The nurse should closely supervise the client for a longer duration, typically 45 to 60 minutes after every meal, to prevent them from hiding food, vomiting, or engaging in excessive physical activity to purge calories.
B. Weighing the client every day during the first week of acute care is a critical and standard intervention. Frequent weight checks are vital for monitoring initial physical stability and assessing fluid status to ensure the client is not developing refeeding syndrome, a dangerous metabolic complication that can occur during early nutritional rehabilitation.
C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.
D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.
Correct Answer is B
Explanation
A. "We can ask the physician to prescribe a sedative": Offering a sedative is not an appropriate immediate response. While medication may be helpful in managing symptoms, the nurse should first assess the client’s emotional state and risk for self-harm.
B. "Have you thought about harming yourself?": This response is the most appropriate as it directly addresses the client’s emotional distress and risk for self-harm. It opens up a conversation for the nurse to assess the severity of the client's suicidal ideation and ensure their safety.
C. "Can a family member try to obtain temporary custody of your child?": While this may be a valid question later on, it shifts the focus away from the client’s current emotional distress and potential self-harm. The immediate concern should be assessing the client’s safety, not discussing custody.
D. "If you attend counseling, you will get your child back": This response may provide false hope or pressure the client, as there are no guarantees about regaining custody. The nurse should focus on providing support and addressing immediate safety concerns rather than making promises.
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