A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?
The woman is timid and speaks softly when asked about the accident.
spiral fracture on the woman's arm and wrist.
The woman is hyperventilating and appears to be in pain.
Fresh bruises on the woman's shoulder and chest.
The Correct Answer is B
A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.
B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.
C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.
D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, the need for medication confirms a history of hypertension. Hypertension is a major modifiable risk factor for coronary artery disease and warrants ongoing assessment.
B. Family health history: A strong family history of heart disease and diabetes, particularly in first-degree relatives, significantly increases the client’s risk for cardiovascular events. The genetic predisposition should be explored to assess early markers and implement prevention strategies.
C. Vegetarian diet: A vegetarian diet is generally associated with lower cardiovascular risk due to reduced intake of saturated fats and cholesterol. Unless the diet is poorly balanced or nutrient-deficient, it does not constitute a risk factor that requires further evaluation here.
D. Sexual history: Sexual history may be relevant in certain clinical contexts, such as evaluating HIV risk or sexually transmitted infections, but it is not directly related to the client's cardiac symptoms or concern about hereditary heart disease.
E. Excessive aerobic exercise: The client’s activity level (jogging) is not excessive and is generally healthy, unless it is associated with overtraining or extreme exertion. There is no indication here that excessive exercise is a concern, so further exploration is not needed based on this information.
Correct Answer is B
Explanation
A. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
B. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
C. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
D. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
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