Which approach would be most appropriate when counseling a client who is a suspected victim of intimate partner violence?

Ask, "Have you ever been physically hurt by your partner?"

Offer the client a pamphlet about the local shelter for victims of intimate partner violence.

Call the client at home to ask some questions about the marriage.

Wait until the client comes in a few more times to make a better assessment.

Answer and Explanation

The Correct Answer is A

A. Ask, "Have you ever been physically hurt by your partner?":

This approach involves directly asking the client about their experience with intimate partner violence. While it's crucial to address the issue openly and directly, some clients may feel uncomfortable or unsafe disclosing abuse, especially during an initial encounter. However, for many clients, this direct approach can be empowering and may facilitate disclosure.

B. Offer the client a pamphlet about the local shelter for victims of intimate partner violence:

Providing informational resources about local shelters and support services can be a supportive and non-confrontational way to offer assistance to a client who may be experiencing intimate partner violence. It allows the client to access resources privately and at their own pace. However, it may not lead to immediate disclosure or intervention.

C. Call the client at home to ask some questions about the marriage:

Calling the client at home to inquire about their relationship may inadvertently escalate the situation and put the client at risk if the abusive partner overhears the conversation. It can also violate the client's privacy and autonomy, as they may not be comfortable discussing sensitive issues over the phone, especially if the abusive partner is present.

D. Wait until the client comes in a few more times to make a better assessment:

Delaying assessment and intervention can potentially prolong the client's exposure to abuse and increase their risk of harm. Intimate partner violence often escalates over time, so it's essential to address suspected abuse as soon as possible to ensure the client's safety and well-being.

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Correct Answer is C

Explanation

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

- This option is not appropriate because after a right-sided modified-radical mastectomy, it's generally contraindicated to use the affected arm (right arm in this case) for blood pressure measurements, IV lines, or blood draws. This is because such procedures can impede lymphatic drainage and increase the risk of lymphedema. Therefore, the unaffected arm is typically preferred for these purposes to reduce the risk of complications.

B. Encourage her to turn, cough, and deep breathe at frequent intervals.

- While turning, coughing, and deep breathing are essential postoperative nursing interventions to prevent respiratory complications such as pneumonia, they are not specific to the unique needs of a woman who has undergone a mastectomy. These interventions are more focused on general postoperative care rather than addressing the specific concerns related to mastectomy, such as lymphedema management.

C. Position her right arm below heart level.

- This is the correct choice. Positioning the right arm below heart level helps reduce swelling and promotes lymphatic drainage, particularly after surgery involving the lymph nodes, as in a mastectomy. This positioning aids in preventing complications such as lymphedema and supports optimal circulation and fluid balance in the affected arm.

D. Ask the client how she feels about having her breast removed.

- While emotional support and addressing the client's feelings are important aspects of care for a woman who has undergone a mastectomy, this intervention is more appropriate during psychosocial assessment and counseling sessions, rather than immediately postoperatively. At this stage, the focus should be primarily on physical recovery and addressing immediate postoperative needs, such as pain management and prevention of complications like lymphedema. Emotional support can certainly be provided, but it should not be the primary intervention immediately following surgery.

A. immunization B. prenatal screening C. antibody titer screening D. frequent handwashing

Correct Answer is D

Explanation

A. Immunization:

Currently, there is no licensed vaccine available for the prevention of cytomegalovirus (CMV) infection. Therefore, immunization is not a viable option for preventing CMV infection during pregnancy. While researchers are actively working on developing a CMV vaccine, it is not yet available for widespread use.

B. Prenatal screening:

Prenatal screening for CMV is not routinely performed during prenatal care. Screening for CMV during pregnancy is not typically recommended unless there is a specific clinical indication, such as maternal symptoms suggestive of acute CMV infection or fetal abnormalities detected on ultrasound. Therefore, prenatal screening is not a primary preventive measure for CMV infection during pregnancy.

C. Antibody titer screening:

Antibody titer screening for CMV is also not routinely performed during prenatal care. While some healthcare providers may offer CMV antibody testing in certain situations, such as for women with a known exposure to CMV or those at increased risk of primary CMV infection during pregnancy, it is not a standard practice for all pregnant women. Therefore, antibody titer screening is not a primary preventive measure for CMV infection during pregnancy.

D. Frequent handwashing:

Frequent handwashing is the most important preventive measure for reducing the risk of CMV infection during pregnancy. CMV is commonly transmitted through close contact with bodily fluids, such as saliva, urine, blood, and genital secretions. Proper hand hygiene, including washing hands with soap and water for at least 20 seconds, especially after coming into contact with young children's saliva or urine, can help prevent the spread of CMV. This measure is crucial for pregnant women to reduce their risk of acquiring CMV and transmitting it to their unborn babies.

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Which approach would be most appropriate when counseling a client who is a suspected victim of intimate partner violence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

Correct Answer is C

Explanation

A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse include as a priority?

Correct Answer is D

Explanation

A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant?

A nurse is assessing a female client and suspects that the client may have endometrial polyps based on which clinical manifestation?

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

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The nurse reviews the CD4 cell count of a client who is HIV-positive. A result less than which count would indicate to the nurse that the client has AIDS?

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?