Nokea
A patient with swelling and a laceration above the right eye states, 'I don't know what caused me to fall and cut my head on the door frame in my bedroom. I'm lucky my spouse was home to take me to the hospital.' The patient's spouse appears nervous but smiles when mentioning that the patient is 'so clumsy at times.' Which nursing intervention should the nurse give priority attention to when addressing this patient's needs?
Correct Answer: A
Rationale: The correct answer is A: Provide a thorough assessment that includes a focus on signs of old injuries. This is the priority intervention because the patient's statement, combined with the spouse's behavior, raises suspicion of potential domestic abuse. By assessing for signs of old injuries, the nurse can gather crucial information to determine if the patient is a victim of abuse.
Choice B: Interview the patient regarding the circumstances surrounding this suspicious fall may be important, but assessing for signs of old injuries takes priority as it provides concrete evidence of potential abuse.
Choice C: Directly ask the patient if spousal abuse is occurring or has ever occurred is necessary, but the patient may not feel comfortable disclosing abuse directly. Assessing for old injuries can provide objective evidence.
Choice D: Notify security that there is a possibility that this patient is a victim of physical abuse is premature without concrete evidence. Assessing for old injuries should be done first to gather information before taking further action.