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","C","D"]
Explanation
Rationale:
A. Interventions should be planned and adapted based on the family’s specific context and needs. They are not completely unstructured but should be flexible and responsive.
B. The nurse-family relationship is central to the CFIM, facilitating effective communication and collaboration.
C. Focusing on family strengths and resiliency is a key aspect of the CFIM, aiming to build on what the family does well to improve functioning.
D. Interventions should be tailored to each family’s context and guided by their specific beliefs and experiences.
E. Family interventions aim to support and improve family functioning rather than correct all issues. The goal is not to resolve every problem but to enhance overall family functioning and support.
Correct Answer is C
Explanation
Rationale:
A. Asking the client if they are comfortable calling 9-1-1 is an appropriate action. It involves assessing the client's readiness and comfort level in seeking emergency help.
B. A nurse-client dialogue about specific steps the client can take to stay safe is important for empowering the client with knowledge and strategies for protection.
C. Insisting that the client act on the plan the next time their safety is threatened may be inappropriate as it can impose undue pressure on the client, who might feel trapped or fearful. The nurse should support the client's choices and provide options rather than insist on actions.
D. A nurse-client dialogue about the potential barriers to safety is crucial for understanding and addressing obstacles that might prevent the client from seeking help or staying safe.