A client comes to the clinic complaining of headaches. Further assessment reveals three one-inch bald spots at different locations on the client's scalp. The client states the headache and the bald spots resulted from an "accident."
The client's partner, who has accompanied the client into the exam room, often finishes the client's sentences. The nurse should:
1. Ask the partner to remain in the waiting room while the client is examined.
2. Alert hospital security about the potential for violence.
3. Encourage the partner to remain with the client to provide information about the client's health.
4. Contact the local authorities.
1
Rationale: An implausible explanation for a client's injuries and a partner's pattern of finishing the client's sentences should arouse the nurse's suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.
You might also like to view...
Nurse Maryse invites a recently discharged patient's family to attend an outpatient support group. This type of program would most likely help the family with which of the following issues?
A. Learning from others in the same situations B. Gaining insight into why they feel guilty C. Recognizing the client's weakness D. Managing the client's financial concern and problems
Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.)
a. Down syndrome b. Molar pregnancy c. Twin gestation d. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy e. Threatened abortion
The nurse is caring for a young adult patient who is receiving a first dose of flurazepam (Dalmane) as a sedative-hypnotic medication. What intervention will be included in the nurse's plan of care for this patient?
a. Instituting a bed alarm system to prevent falls b. Reassuring the patient that nightmares are not a usual effect c. Reporting a urine output greater than 1500 mL/day d. Teaching the patient that this drug may be used for 6 to 8 weeks
With receptive dysphasia (fluent), the individual is able to:
a. Respond in writing, but not in speech. b. Produce verbal speech, but not comprehend language. c. Comprehend speech, but not verbally respond. d. Neither respond verbally nor comprehend speech.