A victim of spousal abuse comes to the emergency department for ...

[yoroshambo]

A victim of spousal abuse comes to the emergency department for treatment of a broken nose. She
  appears hypervigilant and anxious and admits
 
  to sleep disturbance when the nurse questions the dark
  circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has
  been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home
  mother of two preschool children. The family has lived in this town for 1 month. The client states
  she has fleetingly considered suicide but must stay alive to care for her children. She denies having
  had the desire to kill her husband. The assessments the nurse should document in the medical record
  include noting that (more than one option may be correct)
  A. signs of high anxiety and chronic stress are present.
  B. the client relies on the perpetrator for basic needs.
  C. the client is isolated from individual and community support.
  D. suicide risk is high.
  E. homicide potential is low.
  F. a safety plan should be constructed.

Question 2

Symptoms the nurse should expect to confirm for an individual who has just shot up with heroin
  are
 
  a. anxiety, restlessness, and paranoid delusions.
  b. muscle aching, dilated pupils, and tachycardia.
  c. heightened sexuality, insomnia, and euphoria.
  d. drowsiness, constricted pupils, and slurred speech.

[alexanderhamilton]

Answer to Question 1

A, B, C, E, F
Rationale: Option A: Client and family coping is impaired as evidenced by client symptoms,
recently sustained physical abuse, and perpetrator substance abuse and overcontrolling aspects of
family life. Option B: Powerlessness is evident. Option C: The client does not have support systems
available. Option E: The scenario supports this assessment. Option F: Because the client has already
sustained physical injury, and the perpetrator abuses alcohol and is both jealous and obsessive about
the relationship, risk for further injury is high. The client should have a plan for going to a safe site
in the event this becomes necessary. Option D: Data do not support the assessment that the client's
suicide risk is high.

Answer to Question 2

D
Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased and
attention will be impaired. Option A describes behaviors consistent with amphetamine use. Option B
describes symptoms of narcotic withdrawal. Option C describes cocaine use.