Examkin

Question

Difficulty: MediumAbuse or Neglect

A practical nurse is assisting with the care of a 32-year-old client in the emergency department who has sustained a fractured wrist. The client looks down and softly states, "I am so clumsy, I just tripped over a rug." The nurse observes that the client's partner is pacing the room aggressively, answering all questions directed at the client, and refusing to leave the bedside. Which action should the nurse take first?

  1. A
    Wait to notify the charge nurse about the suspected abuse until the healthcare provider confirms the injury pattern is non-accidental.
  2. Fabricate a routine clinical reason, such as obtaining a urine specimen, to speak with the client privately.Answer
  3. C
    Ask the client directly in front of the partner, "Why are you letting your partner answer all of the questions?"
  4. D
    Discuss the partner's suspicious behavior with the registration clerk in the open triage area to gather more information.

Answer

Fabricate a routine clinical reason, such as obtaining a urine specimen, to speak with the client privately.
When intimate partner violence is suspected, the immediate priority is to ensure the client's safety and provide a secure, private environment for disclosure. Because the partner is refusing to leave and controlling the conversation, the nurse must use a creative, routine clinical reason to separate the client from the suspected abuser without arousing suspicion or escalating the partner's aggression.

Step-by-Step Solution

1
Identify the behavioral cues indicating potential intimate partner violence.
The partner answering for the client, refusing to leave, and the client's submissive behavior (looking down) are classic red flags for abuse.
Recognizing signs of abuse is the first step in protecting a vulnerable client.
2
Determine the most immediate need for the client based on the assessment.
The immediate priority is to ensure the client's safety and provide a secure environment for a private assessment.
A client cannot safely disclose abuse if the suspected abuser is present.
3
Select the safest intervention to separate the client from the partner.
Using a routine clinical reason (like a restroom visit for a urine sample) separates them without arousing suspicion.
Direct confrontation could trigger the abuser and place the client at imminent risk of further harm.

Key Concept

Prioritizing client safety and establishing a private environment when intimate partner violence is suspected.
Rate this question

Topics

Abuse or Neglect

More questions from this topic