The nurse has been working with a family at the community health office and is concerned about signs of family violence. Which finding should the nurse identify as most concerning?
1. The baby always seems to have a cold.
2. One of the children never speaks and seems "on guard" when in the presence of a parent.
3. The family's clothes are relatively clean, but the children usually have some kind of dirt stain on their shirts or pants.
4. The family does not have a regular physician.
Correct Answer: 2
Rationale 1: The baby may have an untreated condition, but chronic cold symptoms are not evidence of abuse.
Rationale 2: A child who doesn't speak and is watchful when parents are near would be a significant indicator of a possible abuse situation.
Rationale 3: Dirty clothes or clothes not meeting the nurse's standards are not signs of abuse—maybe for this family, appearance is not a high priority.
Rationale 4: Not having a regular physician would be a concern for health promotion and maintenance, but not for abuse.
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