The nurse in the emergency department is triaging a client with multiple burns and bruises to the upper and lower extremities. The client states that her spouse gave her these injuries during an argument. The nurse should take which initial action?
The nurse in the emergency department is triaging a client with multiple burns and bruises to the upper and lower extremities. The client states that her spouse gave her these injuries during an argument. The nurse should take which initial action?
A. Assess and treat the injuries
[58%]
B. Consult a social worker for discharge planning
[2%]
C. Establish a therapeutic rapport
[18%]
D. Report the alleged abuse to authorities
[22%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Abuse/Neglect
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Abuse/Neglect
Item Type
Item Type
Application
Explanation
Choice A is correct. The initial concern for the client is her physical stability. The nurse should always put physical needs first; in this case, the nurse should initially assess and treat the wounds. By addressing the client's bodily injuries, the nurse can move on to keep the client safe by providing reassurance, establishing a therapeutic rapport, and reporting the alleged domestic violence incident to authorities.
Choices B, C, and D are incorrect. These actions are appropriate for the nurse to take during this client situation. The nurse should cultivate a therapeutic rapport with the client and provide a safe and private environment. Discharge planning to a secure facility/shelter should be considered during the course of treatment. The nurse may collaborate with the social worker to assist in this process. Reporting the incident to authorities is essential because nursing professionals, in most jurisdictions, are mandatory reports of suspected abuse.
Related Videos
2 Key Topics
Abuse
13.1 Psychosocial Stressors & Coping
Additional Info
✓ Intimate partner violence (IPV) could be a current or previous partner or spouse
✓ IPV occurs in heterosexual and same-sex relationships where intimacy may not be present
✓ Nurses should assess all clients for IPV
✓ IPV may be physical, psychological (emotional), sexual, financial, stalking, neglect, or abandonment
✓ Nurses should inform clients that information regarding IPV will be kept confidential and shared with the treating physician
✓ The nurse should also inform the client that most jurisdictions require reporting of IPV; the nurse should inform the client that any IPV will be reported
✓ Interactions between the victim and the perpetrator may demonstrate the victim seeking approval from the perpetrator, the perpetrator reluctant to leave the victim alone, or frequent interruptions during the assessment
✓ Cases of IPV reported by the nurse are kept anonymous, and that should not dissuade the nurse from reporting
✓ It is not enough for the nurse to report suspicions of abuse to the supervisor; that does not absolve the nurses' legal and ethical responsibility to report the IPV
