A nurse is caring for client who experienced abuse. The client says, "It was my fault. I made my partner upset." The nurse should identify that the client is demonstrating which of the following manifestations?

Fear

Guilt

Dependency

Anger

Answer and Explanation

The Correct Answer is B

A. Fear is a common response among abused clients, often manifesting as worry about personal safety or anticipating harm. Statements indicating fear usually focus on external threats, such as “I’m afraid of what my partner will do next.” While fear is important to assess and address, the client’s statement in this case is about self-blame, not imminent danger.

B. Guilt reflects the client’s internalized responsibility. Survivors of abuse may feel shame or culpability, which can lead to hesitation to seek help, depression, or lowered self-esteem. Recognizing guilt allows the nurse to provide empathic support, validate that the abuse is not the client’s fault, and offer counseling or therapeutic interventions.

C. Dependency involves reliance on another person for emotional, financial, or physical support. Although dependency can coexist in abusive relationships, the client’s statement does not indicate reliance or helplessness, it centers on blaming themselves for the partner’s actions.

D. Anger can be directed toward oneself or the abuser. While self-directed anger may coexist with guilt, the client’s statement does not reflect anger but rather acceptance of blame, indicating guilt rather than rage or frustration.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E","F"]

Explanation

A. "The client states that their rings and necklaces are missing." is correct. Missing personal property, especially valuable items, is a common indicator of financial or physical exploitation among older adults.

B. "The client states they are suddenly unable to log into their online bank account." is correct. Sudden loss of access to financial accounts can indicate unauthorized use or manipulation by another person, which is a red flag for financial exploitation.

C. "The client states that their bank account has unexplained withdrawals of money." is correct. Unexplained financial activity is a hallmark sign of potential exploitation, especially when the client is not aware of these transactions.

D. "The client states that the mortgage payment is set on an automatic bank draft." is not necessarily a sign of exploitation. Automatic payments are a common and legitimate method of paying bills and do not alone indicate abuse.

E. "The client states that the money in their safety deposit box has decreased over the past few months." is correct. Missing funds from secure storage suggest someone may be taking advantage of the client, signaling financial exploitation.

F. "The client states they received a disconnection notice for the light bill after a family member stated they would pay it." is correct. This may indicate mismanagement or withholding of funds by a trusted person, which is another indicator of financial exploitation.

A. Encourage the client to express pain using long sentences. B. Administer pain medications based on verbal reports only. C. Monitor for behavioral cues such as guarding or grimacing. D. Presume no pain unless the client reports it directly.

Correct Answer is C

Explanation

A. Encouraging the client to express pain using long sentences is inappropriate. Elderly clients with cognitive impairment may have difficulty articulating pain verbally, so expecting complex verbal descriptions can lead to underassessment.

B. Administering pain medications based on verbal reports only is insufficient. Clients with cognitive impairment may underreport or be unable to communicate pain, so relying solely on verbal reports risks undertreatment.

C. Monitoring for behavioral cues such as guarding or grimacing is correct. pain assessment in cognitively impaired elderly emphasizes that nonverbal indicators—facial expressions, body movements, vocalizations, changes in activity or sleep patterns—are key to recognizing pain in this population. Nurses must assess pain through both behavioral and physiological cues, ensuring timely and appropriate pain management.

D. Presuming no pain unless the client reports it directly is unsafe and can lead to undertreatment and unnecessary suffering. Cognitive impairment often limits verbal reporting, making proactive assessment essential.

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A nurse is caring for client who experienced abuse. The client says, "It was my fault. I made my partner upset." The nurse should identify that the client is demonstrating which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse has been caring for a client for the past three months. Which of the following findings suggest the client is experiencing potential exploitation? (Select All that Apply.)

Correct Answer is ["A","B","C","E","F"]

Explanation

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Correct Answer is C

Explanation

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