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Zorluk: OrtaAbuse or Neglect

While collecting admission data on a medical-surgical unit, a practical nurse observes a client with fading contusions on the upper arms. The client's spouse answers every question on the client's behalf and refuses to step away from the bed. The client appears visibly withdrawn and avoids eye contact. Which action is the priority for the practical nurse to take?

  1. Use a routine clinical rationale, such as obtaining a urine specimen, to separate the client from the spouse.Cevap
  2. B
    Directly ask the client about the contusions while the spouse is standing at the bedside.
  3. C
    Document the observations and wait for the client to explicitly disclose any incidents of domestic violence.
  4. D
    Reassure the client that they are completely safe in the hospital and have nothing to worry about.

Cevap

The practical nurse should use a routine clinical rationale to separate the client from the spouse in order to safely and privately assess the situation.
When intimate partner violence is suspected, the immediate priority is to ensure the client's safety. The most appropriate initial action is to separate the client from the suspected abuser using a routine, non-suspicious clinical rationale (such as collecting a specimen or taking them to an X-ray). This allows the nurse to ask targeted safety questions in private without alerting the abuser or putting the client at greater risk of retaliation.

Adım Adım Çözüm

1
Identify the behavioral cues and physical findings that suggest potential intimate partner violence.
The nurse recognizes the controlling behavior of the spouse, the client's withdrawn demeanor, and the unexplained fading contusions as critical red flags.
Early recognition of abuse indicators is essential for initiating appropriate safety measures.
2
Determine the safest method to gather more information without escalating the situation or endangering the client.
The nurse plans to separate the client from the spouse to conduct a private screening.
Victims of abuse are highly unlikely to disclose information or admit to feeling unsafe if the suspected abuser is present.
3
Implement a non-threatening intervention to achieve privacy.
The nurse uses a standard clinical task, such as escorting the client to the bathroom for a urine specimen, to separate them naturally.
This approach avoids raising the abuser's suspicion while allowing the nurse the necessary privacy to ask direct safety questions.

Anahtar Kavram

Intimate Partner Violence (IPV) Safety and Assessment
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Konular

Abuse or Neglect

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