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. 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.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Cultural imposition occurs when a nurse enforces their own cultural norms and practices on clients, such as not allowing them to choose whether to bathe daily.
B. Insisting that a client see a priest based on personal beliefs imposes religious practices on the client, not considering their individual preferences or needs.
C. Treating all clients the same without considering cultural differences is not cultural imposition but rather a lack of cultural competence.
D. Dismissing Jewish dietary restrictions as merely a preference reflects a lack of respect for the client's cultural practices, which is an example of cultural imposition.
E. Directing questions to the client's daughter instead of the client shows a lack of respect for the client's autonomy but does not exemplify cultural imposition.