Nursing Interventions
What is the priority intervention for a client who has just disclosed intimate partner violence?
Develop a Safety Plan.
Ensure the client is safe. If children are involved, ensure their safety.
Best initial response when a client says, "I don't want to go home — he might hurt me again."
"You're not alone, and help is available. Let's talk about a plan to keep you safe."
A toddler presents with bruises in various stages of healing. This may indicate:
Child abuse
Can a toddler have bruising? If so, where would it be expected?
This diagnosis reflects a child's inability to escape a threatening environment due to neglect or physical harm.
Risk for injury
One key difference between PTSD and RTS.
RTS is specific to sexual assault survivors; PTSD can result from any trauma.
This type of abuse in elderly clients may present with poor hygiene, dehydration, and untreated medical issues.
Neglect
When a child discloses abuse, the nurse should avoid this type of question.
Avoid leading or suggestive types of questions
An elderly client’s caregiver appears nervous and refuses to leave the room. This may be a red flag for:
Elder abuse or caregiver intimidation
Often seen in survivors of IPV, this diagnosis involves feelings of helplessness and lack of control over one's situation.
Powerlessness
A trauma therapy that has clients revisit the trauma site in a safe, controlled way.
Exposure therapy
Before reporting suspected child abuse, what should the nurse first ensure?
The child is safe and immediate needs are addressed
A nurse’s nonverbal cues should include these two things when talking to trauma survivors.
Calm tone and open body language
These are two hallmark symptoms of PTSD.
Flashbacks and hypervigilance
This diagnosis may be used for older adults who are withdrawn and lack social contact due to neglect or abuse.
Social Isolation
One way the nurse knows PTSD treatment is effective.
The client reports fewer flashbacks or improved sleep
When caring for a rape survivor in the ED, this should be done before a physical exam.
Obtain informed consent
A helpful response when a rape survivor says, “I should have fought back.”
"You are not to blame for what happened."
After a sexual assault, clients with Rape Trauma Syndrome (RTS) often initially appear like this.
Calm or detached (a sign of shock or dissociation)
A common diagnosis for individuals with PTSD, it involves recurring flashbacks, nightmares, and hypervigilance.
Post-Trauma Syndrome
This evidence-based therapy for PTSD involves identifying and changing distorted thinking.
cognitive behavioral therapy (CBT)
An appropriate nursing intervention for PTSD involving flashbacks and hyperarousal.
Help the client identify triggers and practice grounding techniques
The nurse should avoid this response when a PTSD client cries during a session.
Changing the subject or minimizing their feelings
A client repeatedly returns to an abusive partner. This behavioral pattern is associated with:
The cycle of abuse or learned helplessness
This diagnosis is appropriate for someone experiencing emotional abuse and manipulation, leading to a diminished sense of self-worth.
Chronic Low Self Esteem
Three signs/symptoms of PTSD.
Flashbacks, nightmares, avoidance of triggers, hypervigilance, irritability, or emotional numbness