A young client is brought into the emergency department by a ...

[MGLQZ]

A young client is brought into the emergency department by a friend who says the client was beat up at school. The client is reluctant to provide the names of parents or a home address.
 
  Which should the nurse suspect has occurred with this client?
  A) The client does not want the individual who did the beating to get in trouble.
  B) The client does not know his parents.
  C) The client does not want the school to get in trouble.
  D) The client is a victim of interpersonal violence.

Question 2

A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD) who was admitted to the hospital for suicide ideations and sleep disturbance due to frequent nightmares.
 
  Which is the priority nursing diagnosis for this client?
  A) Disturbed Sleep Pattern
  B) Post-Trauma Syndrome
  C) Risk for Other-Directed Violence
  D) Risk for Self-Directed Violence

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Answer to Question 1

Answer: D

Although the nurse may initially believe that the client is telling the truth about being beaten up at school, the client's reluctance to provide parents' names or address could suggest the client is a victim of interpersonal violence. Reluctance to provide personal information could mean fear of further abuse. It is unlikely that the client does not know his parents. It is also unlikely that the client does not want to get the school or the individual who did the beating in trouble.

Answer to Question 2

Answer: D

Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore Risk for Other-Directed Violence would not be appropriate for this client.