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 A
Explanation
Rationale:
A. Nurses are mandated reporters and must report suspicions of abuse or neglect, regardless of concrete evidence or verbal admission.
B. A verbal admission from the victim is not required; suspicions alone are sufficient to make a report.
C. While notifying a supervisor may be part of internal protocols, it is not a legal requirement for making a report.
D. Notifying the parents may not be safe or appropriate in cases of abuse, and it is not a requirement for reporting abuse or neglect.
Correct Answer is B
Explanation
Rationale:
A. Spirituality is a sense of devotion to one or more gods is too narrow and may not encompass the broader concept of spirituality, which can include personal beliefs and practices beyond organized religion.
B. Many religions have cultural and ethical underpinnings accurately reflects how religion and spirituality influence health care decisions by providing a framework for values and behaviors.
C. Religion represents a group's philosophy may be more about religion than spirituality and does not fully encompass personal spiritual beliefs.
D. Those with a high sense of spirituality may not necessarily follow a prescribed set of beliefs, as spirituality can be highly individualized and not always tied to specific religious doctrines.