Warning Signs
A client begins pacing, clenching their fists, and speaking loudly. What behavior is the nurse recognizing?
Early signs of escalating agitation or potential aggression.
An angry client begins shouting at the nurse. What is the most appropriate initial communication approach?
Speak calmly and acknowledge the client's feelings without arguing.
A child presents with bruises in different stages of healing, and the caregiver provides inconsistent explanations. What should the nurse suspect?
Possible child physical abuse.
A client experiencing intimate partner violence states, "I don't know why I keep going back." What communication approach should the nurse use?
Nonjudgmental, empathetic communication.
A client arrives at the emergency department following a sexual assault. What is the nurse's initial priority?
Assess and stabilize immediate physical and psychological safety needs.
A client who experienced sexual assault asks why a specially trained nurse has been called to the emergency department. What is this nurse commonly called?
Sexual Assault Nurse Examiner (SANE).
A client becomes increasingly restless after being told they cannot leave the unit. What should the nurse assess before the behavior escalates?
The client's emotional state, immediate needs, potential triggers, and risk for violence.
A nurse is communicating with an agitated client. Why should the nurse avoid standing directly in front of the client or blocking the doorway?
To reduce feelings of being trapped or threatened and maintain a safe exit.
An older adult appears malnourished, has poor hygiene, and is frequently left alone despite needing assistance with basic care. What type of mistreatment should the nurse consider?
Neglect
A nurse suspects intimate partner violence. Why is it important to interview the client without their partner present?
To promote privacy, safety, and the client's ability to speak freely.
A client reports a sexual assault and appears emotionally withdrawn. What should the nurse avoid assuming?
That the absence of visible distress indicates the assault did not occur or that the client is unaffected.
A client becomes visibly uncomfortable when the nurse approaches to perform an assessment. What should the nurse do?
Explain each step, ask permission before touching the client, and offer choices whenever possible.
A client experiencing escalating anger begins speaking rapidly and making threatening statements. What change in communication should the nurse make?
Use a calm, nonthreatening tone, brief statements, and clear expectations.
A client becomes increasingly agitated in a crowded dayroom. What environmental intervention may help prevent escalation?
Offer a quieter, less stimulating environment.
A client repeatedly visits the emergency department for injuries and appears fearful when their partner answers questions for them. What should the nurse assess?
Possible intimate partner violence.
A client experiencing intimate partner violence states that they are not ready to leave the relationship. What should the nurse do?
Respect the client's autonomy, assess safety, and offer resources and safety-planning assistance without pressuring the client.
A client arrives after a sexual assault and requests to shower before an examination. What should the nurse explain?
Showering may affect the collection of forensic evidence, but the client retains the right to decide whether to shower or participate in the collection.
A client who experienced sexual assault reports nightmares, hypervigilance, and difficulty sleeping several weeks later. What condition should the nurse consider assessing for?
Posttraumatic stress disorder (PTSD), while recognizing that trauma-related symptoms do not automatically establish the diagnosis.
A client with a history of aggression suddenly becomes quiet after yelling and threatening staff. Why should the nurse remain alert?
Sudden calmness does not necessarily indicate resolution and may precede an aggressive act.
A client threatens to strike another client. What should the nurse prioritize?
Protect everyone from immediate harm, summon assistance, and use the least restrictive safe intervention.
An older adult reports that a family member controls their bank account and frequently withdraws money without permission. What type of abuse is suspected?
Financial exploitation.
A nurse is documenting suspected abuse. Which type of documentation is most appropriate?
Objective descriptions of injuries, assessment findings, and the client's statements using direct quotations when possible.
A client who experienced sexual assault repeatedly apologizes and states, "I should have done something differently." What is the most therapeutic response?
"You are not responsible for what happened to you."
A client asks why emergency contraception and testing for sexually transmitted infections are being discussed after a sexual assault. What should the nurse explain?
These are options to address potential pregnancy and infection risks, and the client may make informed decisions about recommended care.
A nurse notices that a client's agitation consistently increases during shift change. What should the nurse evaluate to reduce future episodes?
Environmental triggers, changes in routine, unmet needs, and staff interactions.
A client is placed in restraints following an episode of dangerous aggression. What ongoing nursing responsibility is essential?
Monitor physical and psychological status, circulation, respiratory function, and continued need for restraints according to policy and applicable requirements.
A caregiver reports that a child's injury occurred during a minor fall, but the injury pattern is inconsistent with the explanation. What should the nurse do?
Assess and document objective findings, ensure immediate safety, and follow mandated reporting requirements for suspected child abuse.
A client experiencing intimate partner violence reports that their partner recently threatened to kill them and has access to a firearm. What is the nurse's priority?
Assess immediate danger and collaborate on urgent safety interventions and appropriate protective resources.
A client presents following a sexual assault and reports genital discomfort but no visible injuries. What should the nurse recognize?
Sexual assault may occur without visible physical injuries; the absence of injuries does not exclude assault.
A client becomes tearful during a forensic examination and asks the nurse to stop. What should the nurse do?
Stop the examination, assess the client's needs, provide emotional support, and proceed only with appropriate consent.
A previously cooperative client begins pacing near the exit, repeatedly scanning the room, and refusing redirection. What should the nurse prioritize?
Assess the immediate risk for violence, maintain a safe distance and access to an exit, obtain assistance, and initiate appropriate de-escalation interventions.
A client is yelling, throwing objects, and refusing verbal redirection. The healthcare team is considering restraints. What must guide this decision?
Immediate safety, the failure or infeasibility of less restrictive interventions, and the requirement to use restraints only when clinically justified and according to legal and organizational standards.
A nurse suspects an older adult is experiencing abuse, but the client denies mistreatment while the caregiver remains in the room. What is the most appropriate nursing approach?
Arrange a private, supportive assessment, evaluate immediate safety, document findings objectively, and follow applicable reporting requirements.
A client experiencing intimate partner violence plans to return home despite repeated episodes of physical abuse. How should the nurse evaluate the effectiveness of the nursing interventions?
Determine whether the client understands available resources, recognizes safety risks, and has participated in developing an individualized safety plan. Leaving the relationship is not the only measure of successful nursing care.
A client reports sexual assault and agrees to medical treatment but declines a forensic evidence collection examination. What is the nurse's most appropriate action?
Respect the client's informed decision, continue appropriate medical and psychological care, and explain available options and applicable reporting requirements.
A client preparing for discharge after a sexual assault states, "I don't want anyone to know what happened, and I don't think I can handle talking about it again." What is the nurse's best response?
Respect the client's preferences, explain confidentiality and its limits, offer support and follow-up resources, and allow the client to determine when and whether to access additional services.