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After treatment for a detached retina, a victim of intimate partner violence says, 'My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me.' Which nursing diagnosis applies?
- A. Social isolation, related to lack of community support system
- B. Risk for injury, related to partner's physical abuse when intoxicated
- C. Deficient knowledge, related to resources for escape from the abusive relationship
- D. Disabled family coping, related to uneven distribution of power within a relationship
Correct Answer: B
Rationale: Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.
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Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse?
- A. Repeated middle ear infections
- B. Severe colic
- C. Bite marks
- D. Croup
Correct Answer: C
Rationale: Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.
An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, 'It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep.' Which nursing intervention has priority?
- A. Teach the caregiver more about the effects of dementia.
- B. Secure additional resources for the mother's evening and night care.
- C. Support the caregiver to grieve the loss of the mother's ability to function.
- D. Teach the family how to give physical care more effectively and efficiently.
Correct Answer: B
Rationale: The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.
A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. The patient attends anger management classes. Which finding indicates success in this plan of care?
- A. The patient expresses frustration verbally instead of physically.
- B. The patient explains the rationale for behaviors to the victim.
- C. The patient identifies three personal strengths.
- D. The patient agrees to seek counseling.
Correct Answer: A
Rationale: The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.
An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, 'My parents don't like me. They call me stupid and say I never do anything right.' Which type of abuse is likely?
- A. Sexual
- B. Physical
- C. Emotional
- D. Economic
Correct Answer: C
Rationale: Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.
A clinic nurse interviews an adult patient accompanied by a partner who reports fatigue, back pain, headaches, tension, and sleep disturbances. The patient then becomes reluctant to provide more information and wants to leave. How can the nurse best serve the patient?
- A. Explore the possibility of patient social isolation.
- B. Have the partner leave the patient alone to continue the assessment.
- C. Ask whether the patient has ever had psychiatric counseling in the past.
- D. Ask the patient to disrobe so that assessment for signs of physical abuse can occur.
Correct Answer: B
Rationale: In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to speak more candidly if the partner is not in the room. None of the other options focus on the client's reluctance to continue the assessment process.