When should intimate partner violence (IPV) screening occur?

Only when a client presents with an unexplained injury.

As soon as the clinician suspects a problem.

Once the clinician confirms a history of abuse.

As a routine part of each health care encounter.

Answer and Explanation

The Correct Answer is D

A. Only when a client presents with an unexplained injury: Waiting for physical signs misses many victims, especially those experiencing emotional or sexual abuse without visible injuries.

B. As soon as the clinician suspects a problem: While suspicion should prompt further evaluation, relying on suspicion alone delays early detection and intervention for many at-risk individuals.

C. Once the clinician confirms a history of abuse: Screening is a preventive tool used to detect abuse early; waiting for confirmation defeats the purpose and allows ongoing harm.

D. As a routine part of each health care encounter: Routine screening normalizes the process, reduces stigma, and increases the likelihood of identifying and helping those experiencing IPV.

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Correct Answer is D

Explanation

A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.

B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.

C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.

D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.

A. Temperature 99.9° F (37.7° C) B. Respirations 34 breaths/minute C. Heart rate 136 beats/minute D. Weak peripheral pulses E. Dry mucous membranes F. Body mass index (BMI) 21.9 kg/m2 G. Blood pressure 100/52 mm Hg H. Poor skin turgor

Correct Answer is ["C","D","E","G","H"]

Explanation

A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.

B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.

C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.

D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.

E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.

F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.

G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.

H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.

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When should intimate partner violence (IPV) screening occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Correct Answer is ["C","D","E","G","H"]

Explanation

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 nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

The healthcare provider prescribes dalteparin 200 units/kg SUBQ once a day for a client who weighs 154 lb. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A client who is admitted after an episode of status epilepticus is stabilized. Which finding should the nurse use to determine the client's risk for recurrence of seizure activity?

Which oral medication can the nurse safely cut in half?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?