A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

The correct answer is Choice B.

Choice A rationale: Phase IV is not a recognized phase in the cycle of battering. Typically, the cycle of battering consists of three phases: tension-building, acute battering, and honeymoon phase. Each phase has distinct characteristics.

Choice B rationale: Phase I, the tension-building phase, is characterized by increased tension, irritability, and frustration in the abuser. The victim may sense the abuser's declining tolerance for frustration, leading them to try to avoid confrontation by staying out of the abuser's way.

Choice C rationale: Phase III is the honeymoon phase, where the abuser may apologize, show remorse, and be affectionate. The victim may feel hopeful for change. However, this does not match the described behavior of increasing frustration and anger with quick apologies.

Choice D rationale: This is a duplicate of Choice B. As previously stated, Phase I, the tension-building phase, involves the buildup of tension and irritability in the abuser, leading the victim to try to stay out of the abuser's way to avoid conflict.

The correct answer is choice D. A child whose parents answer questions for the child.

Choice A rationale:A child with a BMI indicating obesity is not necessarily a sign of abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. While it is important to address obesity for the child’s health, it does not directly indicate abuse.

Choice B rationale:A child who uses the call light frequently may be seeking attention or reassurance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to anxiety, fear, or a need for comfort, which can be addressed through appropriate nursing care and support.

Choice C rationale:A child who has frequent visitors is generally seen as having a strong support system. Frequent visits from family and friends usually indicate that the child is well-cared for and loved. This is not typically a sign of abuse.

Choice D rationale:A child whose parents answer questions for the child can be a red flag for abuse. This behavior may indicate that the parents are controlling and do not allow the child to speak for themselves, which can be a sign of emotional or psychological abuse. It is important for healthcare providers to observe interactions between the child and parents and assess for any signs of coercion or control.