A nurse conducts a home health or outpatient visit with an adult client. During the interaction:
- The client appears anxious, withdrawn, and hesitant to speak openly
- There are visible bruises in different stages of healing
- When asked privately, the client discloses experiencing emotional and/or physical abuse by a partner
- The client does not want police involvement at this time
- There is no immediate life-threatening injury reported
- The client expresses uncertainty and emotional distress, but is open to support
Following the visit, what are appropriate actions for the nurse? Select all that apply.
Mail education items to the home for batterer treatment options
Provide referrals from the physician for mental health services
Follow up with the client in a few weeks
Call the police as a mandatory reporter
Document verbatim statements about the abuse
Correct Answer : B,C,E
A. Mailing education items to the home for batterer treatment options might not be appropriate without the client's consent or discussion.
B. Providing referrals for mental health services aligns with addressing the client's needs.
C. Following up with the client in a few weeks ensures continuity of care and monitoring of the client's progress.
D. Calling the police as a mandatory reporter might be necessary if there's an immediate threat, but it's not mentioned in the scenario.
E. Documenting verbatim statements about the abuse is crucial for accurate record-keeping and legal purposes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Awareness of signs and symptoms is important, but routine evaluation of lithium levels is crucial for those taking lithium carbonate due to its narrow therapeutic range and potential toxicity.
B. Monitoring serum lithium levels is essential to ensure the medication remains within the therapeutic range and to prevent potential lithium toxicity.
C. Participating in therapy can be beneficial but might not be as critical as monitoring lithium levels for someone newly diagnosed with bipolar disorder.
D. While independence is important, the key concern here is the need for close monitoring of lithium levels due to the medication's potential side effects.
Correct Answer is C
Explanation
A. Initiating an exercise program might be helpful, but it doesn't directly address the delayed responses or aid in communication.
B. Asking the client to describe her depression might be beneficial, but it may not be suitable if the client's responses are delayed.
C. Spending time in silence with the client can create a safe and supportive environment, allowing the client to communicate at her own pace without feeling pressured.
D. Observing for signs of psychosis is important but doesn't directly address the delayed responses.
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