A patient answers "yes" to the nurse's question, "In the past year, have you been hit, kicked, punched, or hurt in other ways by someone close to you?" What next nursing intervention is most important?
a. Conduct a physical exam to assess for signs/symptoms of suspected violence and abuse.
b. Report the suspected violence and abuse to the appropriate state agency.
c. Ask the patient if she feels safe in her current environment or situation.
d. Document physical findings concisely and accurately.
C
If a patient answers "yes" to questions which assess for domestic and intimate partner violence, the next most important nursing intervention is to inquire if the patient feels safe. Most emergency departments have resources available to assist an abused patient into a climate where she can receive help and feel safe. A physical exam should be performed during this visit, but it is not the next most important intervention. Documenting physical findings concisely and accurately is imperative, but the patient's safety is paramount.
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