The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Choice A Reason: Is not responding to other clients on the unit.

While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.

Choice B Reason: Is refusing to take their prescribed mood stabilizer.

Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.

Choice C Reason: Angrily argues with another client stating, “God is dead.”

This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.

Choice D Reason: States, “There is no future when you feel so depressed.”

This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.

Choice A Reason:

Emotional injury and learned helplessness. While emotional injury and learned helplessness are significant consequences of intimate partner violence (IPV), they are not the central factors driving the dynamic of IPV. Learned helplessness refers to a state where the victim feels powerless to change their situation due to repeated exposure to traumatic events. Emotional injury is a result of the abuse but not a driving factor.

Choice B Reason:

Poor communication and social isolation. Poor communication and social isolation can exacerbate the situation but are not the primary factors central to the dynamic of IPV. Social isolation is often a tactic used by abusers to control their victims, but it is a consequence rather than a cause. Poor communication can contribute to misunderstandings and conflicts but is not the root cause of IPV.

Choice C Reason:

Power and control. This statement is correct. The central dynamic of intimate partner violence is the abuser’s desire to exert power and control over their partner. This need for dominance manifests through various abusive behaviors, including physical, emotional, psychological, and financial abuse. The Power and Control Wheel, a tool developed by the Domestic Abuse Intervention Project, illustrates how different abusive tactics are used to maintain control over the victim.

Choice D Reason:

Erratic relationships and vulnerability. Erratic relationships and vulnerability are characteristics often seen in IPV situations but are not central to the dynamic. Vulnerability can make individuals more susceptible to abuse, and erratic relationships can be a symptom of the abuse, but they do not drive the abusive behavior5.