A nurse is assessing a client who presents with injuries and signs that may suggest intimate partner violence. Which of the following statements by the client would most likely indicate the need for further assessment and intervention?
"I have bruises from a recent sports injury."
"I'm experiencing stress from work and it's affecting my health."
"I fell down the stairs and injured my arm."
"I often feel afraid at home, but I don't want to talk about it."
The Correct Answer is D
Rationale:
A. Bruises from a sports injury are less likely to indicate intimate partner violence without additional context.
B. Stress from work is a general issue and does not directly suggest intimate partner violence.
C. A fall down the stairs could be an accident; however, further context is needed to assess if this is related to violence.
D. Fear at home and reluctance to discuss it could indicate underlying intimate partner violence, requiring further assessment and intervention.
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Correct Answer is B
Explanation
Rationale:
A. Observing the client's communication with family might provide some insight but does not directly address the cultural influences on the client’s behavior.
B. Understanding the cultural background is crucial as cultural norms and traditions can significantly influence communication behaviors, such as eye contact and engagement.
C. Asking the client directly might be appropriate but does not take into account potential cultural factors that could influence their communication.
D. Misdiagnosing shyness as a communication issue could be a concern, but recognizing cultural influences helps to ensure that the diagnosis is culturally appropriate.
Correct Answer is C
Explanation
Rationale:
A. Evacuating the workspace may be premature without understanding the cause and extent of exposure. Immediate treatment is essential, but a comprehensive approach is needed.
B. Contacting management and cleaning the area are important but do not address the immediate need to treat the worker or investigate exposure.
C. Treating the client and obtaining a comprehensive exposure history is crucial for identifying the cause and planning further actions. Assessing other potentially exposed workers ensures broader safety.
D. Contacting OSHA is important for regulatory issues, but immediate patient care and investigation should take precedence to address the worker's current health needs.