A nurse is assisting with the care of a 45-year-old female client who is in the emergency department.

Exhibits

Click to highlight the findings from the nurses’ notes that indicate partner violence and should be reported to the provider.

Nurses’ Notes for Highlighting:
Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. Laceration to the left cheek cleansed and covered with an adhesive bandage. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.” Client has been married for 22 years and has two children. Client works part-time and volunteers at a community center. Client is tearful, does not make eye contact, and only speaks when spoken to. Client requests not to notify their partner because they do not want them to have to miss work or worry. Client reports poor appetite and difficulty sleeping.

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.

Laceration to the left cheek cleansed and covered with an adhesive bandage.

Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing.

Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

Client has been married for 22 years and has two children.

Client works part-time and volunteers at a community center.

Client is tearful, does not make eye contact, and only speaks when spoken to.

Client requests not to notify their partner because they do not want them to have to miss work or worry.

Client reports poor appetite and difficulty sleeping.

Answer and Explanation

The Correct Answer is ["A","D","G","H","I"]

The findings that indicate possible partner violence and should be reported to the provider include:

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.
Client is tearful, does not make eye contact, and only speaks when spoken to.
Client reports poor appetite and difficulty sleeping.
Client requests not to notify their partner because they do not want them to have to miss work or worry.
Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

These signs, particularly the bruising in different healing stages, avoidance of eye contact, emotional distress, reluctance to notify the partner, and vague or inconsistent injury explanations, may indicate potential intimate partner violence. Ensuring proper screening, support, and intervention is crucial in situations like these. The client’s safety and well-being should remain a priority, and reporting these findings to the healthcare provider allows for further assessment and assistance.

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Correct Answer is D

Explanation

Choice A rationale

Delirium is characterized by an acute and fluctuating onset of disturbances in attention and cognition that develop over a short period, typically hours to days. A gradual onset is more characteristic of conditions like dementia rather than the rapid changes seen in delirium.

Choice B rationale

Difficulty swallowing, or dysphagia, is not a primary characteristic of delirium. While neurological conditions can cause both delirium and dysphagia, difficulty swallowing is not a core diagnostic criterion for delirium itself. Other conditions should be considered for this specific finding.

Choice C rationale

Slowed, flat speech is more commonly associated with depression or neurological conditions rather than delirium. Delirium typically presents with disorganized thinking and speech that may be rapid, incoherent, or difficult to follow, reflecting the altered level of consciousness and attention.

Choice D rationale

Impaired judgment is a key feature of delirium. The disturbance in attention and cognition affects the ability to process information, think clearly, and make sound decisions. This can manifest as poor understanding of situations, impulsive behavior, and an inability to appreciate potential consequences.

A. "Drink 5 ounces of red wine roughly 30 minutes before bed.”. B. "Stay in bed for 1 hour before getting up if you are unable to sleep.”. C. "Exercise 1 hour before bedtime.”. D. "Limit caffeine to one or two servings during daytime hours.”.

Correct Answer is D

Explanation

Choice A rationale

Consuming red wine before bed, even in small amounts, can disrupt sleep architecture. While alcohol might initially induce drowsiness, it often leads to fragmented sleep later in the night as the body metabolizes it, resulting in poor sleep quality and reduced restorative sleep.

Choice B rationale

Staying in bed for prolonged periods when unable to sleep can create a negative association between the bed and wakefulness. This can increase anxiety about sleep and perpetuate insomnia. It is generally recommended to get out of bed and engage in a relaxing activity until feeling sleepy.

Choice C rationale

Exercising vigorously close to bedtime can be stimulating and raise core body temperature, making it harder to fall asleep. The body needs time to cool down for optimal sleep initiation. It is generally recommended to avoid intense exercise at least a few hours before bed.

Choice D rationale

Caffeine is a stimulant that can interfere with sleep initiation and maintenance. Limiting caffeine intake, especially in the afternoon and evening, can significantly improve sleep quality by reducing its stimulating effects on the central nervous system. Normal caffeine intake should be limited, and eliminating it closer to bedtime is beneficial for sleep.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has delirium.Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night.Which of the following recommendations should the nurse make?

Correct Answer is D

Explanation

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