A victim of spousal abuse comes to the emergency department for treatment of a broken nose. She
appears hypervigilant and anxious and admits
to sleep disturbance when the nurse questions the dark
circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has
been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home
mother of two preschool children. The family has lived in this town for 1 month. The client states
she has fleetingly considered suicide but must stay alive to care for her children. She denies having
had the desire to kill her husband. The assessments the nurse should document in the medical record
include noting that (more than one option may be correct)
A. signs of high anxiety and chronic stress are present.
B. the client relies on the perpetrator for basic needs.
C. the client is isolated from individual and community support.
D. suicide risk is high.
E. homicide potential is low.
F. a safety plan should be constructed.
A, B, C, E, F
Rationale: Option A: Client and family coping is impaired as evidenced by client symptoms,
recently sustained physical abuse, and perpetrator substance abuse and overcontrolling aspects of
family life. Option B: Powerlessness is evident. Option C: The client does not have support systems
available. Option E: The scenario supports this assessment. Option F: Because the client has already
sustained physical injury, and the perpetrator abuses alcohol and is both jealous and obsessive about
the relationship, risk for further injury is high. The client should have a plan for going to a safe site
in the event this becomes necessary. Option D: Data do not support the assessment that the client's
suicide risk is high.
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A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred?
1. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling." 2. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." 3. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." 4. "They pay particular attention to details, which can interfere with the development of relationships."
A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non–burn injured skin disorder?
a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease
A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation?
a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.
Which comments by an adult best indicate self-actualization? Select all that apply
a. "I am content with a good book." b. "I often wonder if I chose the right career." c. "Sometimes I think about how my parents would have handled problems." d. "It's important for our country to provide basic health care services for everyone." e. "When I was lost at sea for 2 days, I gained an understanding of what is important."