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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Encourage the client's family to visit more often: The client is withdrawn, increased visits may feel overwhelming. This approach assumes the client is ready for interaction, which may not be the case, and does not directly address communication barriers.

B. Encourage the client to participate in group activities: This may be premature for a client who is severely withdrawn. Pushing participation too soon may increase distress or resistance, making rapport-building through simpler interactions more effective initially.

C. Engage the client in non-threatening conversations: Starting with gentle, non-intrusive conversations helps build trust and re-establish communication. It meets the client where they are emotionally and lays a foundation for further therapeutic engagement without increasing anxiety or pressure.

D. Schedule a daily conference with the social worker: Daily meetings may not be feasible or welcomed by a withdrawn client. Interventions should first aim to re-establish connection through nurse-client interaction.

A. The client reports he was able to sleep through the night B. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. C. The client reports mild nausea and has no desire to eat breakfast D. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage E. The left arm is warm to touch. F. The client's left shoulder and collarbone are symmetric

Correct Answer is ["A","E","F"]

Explanation

Rationale for Correct Choices:

The nurse assesses the client. The client reports he was able to sleep through the night: Being able to sleep through the night suggests that the client’s pain is adequately managed, indicating progress in terms of pain control post-surgery or trauma care.
The left arm is warm to touch: The warmth of the left arm indicates that circulation has improved from initially cool to touch. This is a positive sign, as it suggests that there are no significant vascular complications following the fracture or trauma.
The client's left shoulder and collarbone are symmetric: Symmetry of the shoulder and collarbone suggests that there is no new displacement or injury to the bones post-trauma or surgery. This is a good sign indicating that the fracture is properly stabilized.

Rationale for Incorrect Choices:

The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers: The numbness, tingling, and inability to move his fingers may indicate nerve involvement, which could be a sign of complications such as nerve compression or injury due to the fracture.
The client reports mild nausea and has no desire to eat breakfast: Mild nausea is expected after anesthesia or pain medications, but continued lack of appetite or worsening nausea may signal complications, such as a delayed reaction to anesthesia or a side effect from medication, which should be monitored.
There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage: While some blood may be expected post-surgery or after trauma, a blood stain of this size should be evaluated for any indication of active bleeding or complications such as hematoma formation. It may not be expected if the bleeding had been controlled.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is ["A","E","F"]

Explanation

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