单选题
Directions. The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number. While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped. " How should the nurse respond?
判断题
Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.
【正确答案】
A
【答案解析】
判断题
Report suspicions of abuse to the local authorities.
【正确答案】
B
【答案解析】
判断题
Assist the client in developing a safety plan for times of increased violence.
【正确答案】
A
【答案解析】
判断题
Call the client's husband to discuss the situation.
【正确答案】
B
【答案解析】
判断题
Tell the client that she needs to leave the abusive situation as soon as possible.
【正确答案】
B
【答案解析】
判断题
Provide the client with telephone numbers of local shelters and safe houses.
【正确答案】
A
【答案解析】The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a non-threatening manner that promotes trust, rather than ordering her to break off her relationship.