A nurse is assisting with the care of a client who has experienced partner violence.

The nurse is collecting data from the client 2 weeks later. For each finding, click to specify whether the finding is unrelated, an improvement, or a worsening of the client's situation.

Physical findings

Client's feelings of responsibility

Statement regarding safety

Report of partner violence

Emotional status

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

• Physical findings: The presence of new ecchymosis on the neck two weeks later indicates continued or escalating physical abuse. This demonstrates that the client is at ongoing risk and that the situation has deteriorated compared to the initial left wrist fracture and forearm bruises.

• Client's feelings of responsibility: The client states, "I brought it on myself," reflecting self-blame. Self-blame is a common psychological response to partner violence that can prevent seeking help and perpetuate victimization, indicating a worsening of emotional and psychological well-being.

• Statement regarding safety: The client reports that the children are safe at home. This shows that, despite ongoing abuse, there is some aspect of the environment that remains secure, representing a relative improvement or protective factor in terms of immediate safety for dependents.

• Report of partner violence: The client continues to experience partner violence, evidenced by new bruising. Although the client may minimize the situation verbally, the physical evidence confirms that the abuse is ongoing and escalating, indicating a worsening situation.

• Emotional status:The client reports frequent mood swings and feelings of being "trapped," demonstrating emotional distress, anxiety, and potential depression. These psychological effects suggest a deterioration in mental health as a result of ongoing abuse.

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Correct Answer is C

Explanation

A. "Based on your admission, this procedure is mandatory.": ECT is a voluntary treatment, and informed consent is required. Stating it is mandatory is misleading and violates ethical and legal standards.

B. "You only need to receive this treatment once.": ECT is typically administered in a series of treatments, often multiple sessions per week for several weeks, depending on the client’s response. One session is usually insufficient for therapeutic effect.

C. "You will be sedated during the procedure.": ECT is performed under general anesthesia with a short-acting sedative and a muscle relaxant. Teaching the client that they will be sedated prepares them for the procedure, reduces anxiety, and ensures informed consent.

D. "The procedure will have no lingering effects.": ECT can have side effects, including short-term memory loss, confusion, and headache. Telling the client there are no lingering effects is inaccurate and could result in unmet expectations or mistrust.

A. A client who is 9 kg (20 lb) over their recommended weight B. A client who is wearing soiled clothing C. A client whose caregiver pays the client's bills D. A client who has a bruise on their shin

Correct Answer is D

Explanation

A. A client who is 9 kg (20 lb) over their recommended weight: Being overweight alone does not indicate caregiver abuse or neglect. Weight changes may result from dietary habits, metabolic issues, or other health conditions, so this requires monitoring but not necessarily an abuse inquiry.

B. A client who is wearing soiled clothing: While soiled clothing may suggest inadequate care, it can also be related to the client’s functional limitations or incontinence. It warrants observation and assessment, but it is not as specific an indicator of abuse or neglect as unexplained injuries.

C. A client whose caregiver pays the client's bills: Caregivers assisting with finances is common in older adult care and does not inherently indicate abuse or neglect. It requires verification of consent and legal authority but is not a direct red flag for mistreatment.

D. A client who has a bruise on their shin: Unexplained bruising, especially in older adults, is a common indicator of physical abuse or neglect. The nurse should interview the client sensitively to assess for the possibility of caregiver mistreatment and ensure the client’s safety.

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A nurse is assisting with the care of a client who has experienced partner violence. The nurse is collecting data from the client 2 weeks later. For each finding, click to specify whether the finding is unrelated, an improvement, or a worsening of the client's situation.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled for electroconvulsive therapy (ECT) for major depressive disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a group of older adult clients who receive home care. Which of the following clients should the nurse interview about the possibility of caregiver abuse or neglect?

Correct Answer is D

Explanation

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A nurse is collecting data from a client regarding the client's sexual behavior. The client laughs and makes an inappropriate sexual comment. Which of the following is an appropriate response by the nurse?

A nurse is assisting with the care of a client who has experienced partner violence. The nurse is collecting data from the client 2 weeks later. For each finding, click to specify whether the finding is unrelated, an improvement, or a worsening of the client's situation.

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A nurse is assisting with the care of a client who has experienced partner violence.

The nurse is collecting data from the client 2 weeks later. For each finding, click to specify whether the finding is unrelated, an improvement, or a worsening of the client's situation.