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 {"dropdown-group-1":"A"}
Explanation
Rationale for Correct Choice:
- Depression: The client has symptoms of depression, such as general malaise, fatigue, decreased appetite, withdrawal, flat affect, and poor hygiene. Additionally, the client reports a significant change in sleep patterns, with an inability to sleep at night. His alcohol consumption could also contribute to depressive symptoms.
Rationale for Incorrect Choices:
- Anxiety disorder: While anxiety can cause fatigue, disrupted sleep, and lack of energy, it typically also presents with heightened nervousness, restlessness, excessive worry, or physical symptoms like rapid heart rate, which are not reported here. The client's withdrawal and lack of energy are more consistent with depression.
- Hypothyroidism: Hypothyroidism can cause fatigue, weight gain, and poor appetite, but the client's low BMI (17.7 kg/m²) suggests that weight loss, rather than gain, is occurring. Additionally, the lack of other hypothyroid symptoms, like constipation or cold intolerance, makes hypothyroidism less likely than depression in this scenario.
Correct Answer is D
Explanation
A. Chicken, yams, pinto beans, and pecans: This meal is not ideal for a client with CKD because pinto beans and pecans are high in potassium and phosphorus, which can be problematic for clients with CKD. Yams are also high in potassium.
B. Steak and baked potato with butter and cheese topping: Steak is high in protein and phosphorus, which can overload the kidneys. Baked potato, especially with cheese, can be high in potassium, which should be monitored in CKD.
C. Canned ham and green beans: Canned ham is often high in sodium, which is not recommended for clients with CKD, as it can exacerbate fluid retention and high blood pressure. Green beans are a good choice, but the sodium content in the ham is a concern.
D. Pasta with fish and an orange: Pasta is low in potassium and phosphorus, and fish provides a good source of protein that is generally easier on the kidneys compared to red meat. This meal is lower in sodium, phosphorus, and potassium, making it a better choice for CKD.
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