When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?

battering

honeymoon

tension-building

reconciliation

Answer and Explanation

The Correct Answer is B

A. Battering: This phase involves the actual violent and abusive behavior, where the perpetrator inflicts harm or abuse upon the victim. It is characterized by physical, emotional, or psychological abuse.

B. Honeymoon: The honeymoon phase follows the period of violence or abuse. During this phase, the perpetrator may apologize, show remorse, and express love and affection toward the victim. The perpetrator may also promise to change their behavior and make efforts to reconcile with the victim.

C. Tension-building: The tension-building phase is characterized by increasing tension, anger, and hostility in the relationship. Minor conflicts and stressors escalate, leading to a buildup of tension between the partners. This phase often precedes the occurrence of the violent or abusive episode.

D. Reconciliation: The reconciliation phase occurs after the violent or abusive episode, during which the perpetrator attempts to reconcile with the victim. This phase may involve apologies, promises to change, and expressions of regret. However, it is important to note that the reconciliation phase may be temporary and may cycle back into the tension-building phase, leading to another episode of violence.

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Correct Answer is A

Explanation

A. Deep tendon reflexes 2+: Deep tendon reflexes are typically assessed to monitor for signs of magnesium sulfate toxicity. A normal finding of 2+ deep tendon reflexes suggests that the client is not experiencing magnesium sulfate toxicity. However, it does not specifically indicate whether the medication is at a therapeutic level.

B. Respiratory rate of 10 breaths/minute: A respiratory rate of 10 breaths/minute is below the normal range, and it could indicate respiratory depression, a potential side effect of magnesium sulfate toxicity. While this finding suggests a potential adverse reaction to the medication, it does not confirm whether the medication is at a therapeutic level.

C. Urinary output of 20 mL per hour: Adequate urinary output is essential for excreting magnesium sulfate and preventing toxicity. A urinary output of 20 mL per hour is within an acceptable range and suggests adequate renal function, which is important for maintaining therapeutic levels of the medication. However, it alone does not confirm whether the medication is at a therapeutic level.

D. Difficulty in arousing: Difficulty in arousing is a concerning sign of magnesium sulfate toxicity and suggests central nervous system depression. It indicates that the client may be experiencing an adverse reaction to the medication and that the dose may need adjustment. While this finding suggests a potential issue with medication dosing or toxicity, it does not confirm whether the medication is at a therapeutic level.

A. "I need to avoid driving to and from work every day." B. "Any blood pressures need to be taken in my right arm." C. "I need to wear gloves when doing any gardening." D. "I should wear clothing with elasticized sleeves."

Correct Answer is D

Explanation

A. "I need to avoid driving to and from work every day."

This statement indicates a misunderstanding of how to minimize lymphedema. Driving itself does not directly contribute to lymphedema. However, activities that involve prolonged or repetitive use of the affected arm, such as gripping the steering wheel while driving for long periods, may increase the risk of developing lymphedema. The nurse should clarify that while driving is generally acceptable, the client should take breaks and perform arm exercises during long drives to promote circulation.

B. "Any blood pressures need to be taken in my right arm."

This statement demonstrates correct understanding. Taking blood pressure measurements, administering injections, or obtaining blood samples from the unaffected arm helps prevent trauma or injury to the arm at risk for lymphedema. This practice helps avoid disrupting lymphatic flow and reduces the risk of developing lymphedema in the affected arm.

C. "I need to wear gloves when doing any gardening."

Wearing gloves during gardening is a recommended precaution to minimize the risk of injury and infection, especially if the client has undergone lymph node removal. This statement reflects appropriate understanding and adherence to preventive measures to protect the affected arm from cuts, scratches, and potential infection that could exacerbate lymphedema.

D. "I should wear clothing with elasticized sleeves."

This statement indicates a misunderstanding of how to minimize lymphedema. While elasticized sleeves or compression garments can help manage lymphedema by providing gentle compression and support to the affected arm, wearing tight or constrictive clothing, including elasticized sleeves, can potentially restrict lymphatic flow and exacerbate lymphedema. The nurse should clarify that loose-fitting clothing is preferable to allow unrestricted movement and circulation in the affected arm.

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When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?

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