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 C
Explanation
Rationale:
A. Providing a personal emergency response system is important but does not address the immediate physical hazards in the home that are likely to cause falls.
B. Installing grab bars and handrails is a good safety measure, but addressing immediate tripping hazards should take precedence to prevent falls.
C. Removing clutter and securing loose rugs is a direct intervention that addresses the immediate risk factors for falls in the home environment. This should be the first step in improving safety.
D. Modifying the exercise routine can be beneficial for long-term fall prevention but does not address the immediate physical hazards present in the home.
Correct Answer is D
Explanation
Rationale:
A. Assuming the client will follow the standard care plan without considering cultural beliefs shows a lack of cultural competence. Each client's cultural context should be considered.
B. Requesting conformity to the nurse's beliefs disregards the client’s cultural preferences and is not respectful of their personal values.
C. Avoiding discussion of cultural practices can hinder understanding and appropriate care; addressing cultural practices is important for providing respectful and effective care.
D. Inquiring about the client's cultural beliefs and incorporating them into the care plan ensures that care is respectful, relevant, and tailored to the client's needs and values.