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A nurse is working in the emergency department, and is conducting an interview with a victim of intimate partner abuse. Which step should the nurse take first?

A.

Establish a rapport with the victim and the abuser.

B.

Request the presence of a security guard.

C.

Contact the appropriate legal services.

D.

Ensure privacy for interviewing the victim away from the abuser.

Answer and Explanation

The Correct Answer is D

Rationale:

 

A. Establishing rapport with both the victim and the abuser might not be appropriate in an abusive situation where the victim’s safety is a priority.

 

B. Requesting a security guard may be necessary but should be considered after ensuring the interview environment is safe and private.

 

C. Contacting legal services is important but should come after addressing immediate privacy and safety concerns.

 

D. Ensuring privacy for the interview is crucial to provide the victim with a safe environment where they can speak freely without fear of the abuser’s presence or intervention.


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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.

Correct Answer is A

Explanation

Rationale:

A. Developing an emergency plan is crucial because patterns of violence often continue or escalate, and having a plan can help ensure the client’s safety.

B. While battering patterns often persist, focusing on immediate safety measures like an emergency plan is more practical.

C. Discouraging hope might not be supportive; instead, focusing on practical safety measures is more helpful.

D. Learning self-defense might not address the root issue of the violence and does not ensure safety in abusive situations.

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