One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

Choice A Reason:

Strong negative feelings interfere with assessment and judgment.

This statement is the most accurate explanation for why a nurse needs to be aware of their own feelings while working with a family experiencing domestic violence. Negative emotions such as anger, frustration, or sadness can cloud a nurse’s judgment and hinder their ability to objectively assess the situation. These feelings can lead to biased decision-making, which may compromise the quality of care provided to the victim. For instance, a nurse who feels anger towards the abuser might unconsciously project these feelings onto the victim, affecting their ability to offer unbiased support and intervention. Therefore, maintaining emotional awareness is crucial for ensuring accurate assessments and effective interventions.

Choice B Reason:

Awareness protects one’s own mental health.

While it is true that being aware of one’s feelings can help protect a nurse’s mental health, this statement does not directly address the impact of these feelings on the assessment and judgment process. Emotional awareness is important for self-care and preventing burnout, but the primary rationale for emotional awareness in the context of domestic violence is to ensure that the nurse can provide objective and effective care. Therefore, this choice is not as relevant to the specific question as choice A.

Choice C Reason:

Positive feelings promote the development of sympathy for clients.

Positive feelings such as empathy and compassion are important in nursing, but they can also lead to over-identification with the client, which may result in blurred professional boundaries. While sympathy can foster a supportive relationship, it is essential for nurses to maintain a balance between empathy and professional detachment to provide objective care. This statement does not fully capture the importance of emotional awareness in preventing negative feelings from interfering with assessment and judgment.

Choice D Reason:

Strong positive feelings lead to underinvolvement with the victim.

This statement is less accurate because strong positive feelings, such as empathy and compassion, are more likely to lead to over-involvement rather than underinvolvement. Over-involvement can result in blurred boundaries and difficulty maintaining professional objectivity. However, the primary concern in the context of domestic violence is the interference of negative feelings with assessment and judgment, making this choice less relevant to the question.

a. You are safe now.

Explanation of Choices

Choice A Reason: You Are Safe Now

This statement is the most appropriate because it immediately addresses the client’s need for safety and reassurance. Victims of sexual assault often experience intense fear and anxiety. By reassuring the client that they are now in a safe environment, the nurse helps to stabilize the client’s emotional state and begins to build trust. This statement is crucial in creating a sense of security, which is the first step in providing effective care and support.

Choice B Reason: I’ll Call Your Spouse

While involving a support person can be beneficial, this statement does not address the client’s immediate emotional needs. The priority at this moment is to ensure the client feels safe and supported. Once the client is reassured and stabilized, the nurse can then discuss involving family members or other support persons. Immediate focus should be on the client’s safety and emotional well-being.

Choice C Reason: We’ll Have to Take Photographs of These Wounds

Taking photographs for forensic evidence is an important part of the medical and legal process following a sexual assault. However, this statement is not therapeutic and does not address the client’s immediate emotional needs. Discussing forensic procedures should come after the client feels safe and supported. The nurse should first focus on providing emotional reassurance before moving on to procedural details.

Choice D Reason: The Police Will Want to Interview You

Informing the client about the need for a police interview is necessary, but it is not the priority therapeutic statement at this moment. The client is likely already overwhelmed and distressed. The nurse should first provide reassurance and emotional support before discussing legal procedures. Ensuring the client feels safe and supported is essential before introducing additional stressors.