The nurse working in emergency triage is evaluating a client with injuries frequently associated with physical abuse. Which of the following questions if answered yes by the client would indicate a higher risk of mortality?
"Do you have a gun in your home?"
"Have you ever tried to leave?"
"How many times have you been hospitalized for abuse?"
"Do you have a plan if things go too far?"
The Correct Answer is A
Rationale:
A. The presence of a gun in the home is associated with a higher risk of severe injury or death in cases of domestic violence.
B. While trying to leave can be risky, it does not directly indicate a higher risk of mortality compared to other factors.
C. Repeated hospitalizations indicate ongoing abuse but are not as directly related to immediate risk of mortality as the presence of a gun.
D. Having a plan could indicate awareness and preparation, which may not directly correlate with immediate risk of mortality.
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Correct Answer is C
Explanation
Rationale:
A. While convincing a victim to escape might be a goal, it’s not always feasible or safe to suggest immediate action in such a dangerous situation.
B. Gathering information is important but should be done cautiously, ensuring the victim’s safety and comfort.
C. Being a safe and supportive presence is crucial, as it allows the victim to feel secure and open up at their own pace, which is essential for their safety and trust-building.
D. Providing resources is valuable, but ensuring that the victim feels safe and supported is a priority before sharing resources.
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.