The nurse is caring for a client that is the victim of domestic ...

[theo]

The nurse is caring for a client that is the victim of domestic violence and is visited by the spouse in the hospital. Which action by the nurse supports the client?
 
  A) Call the police to have the spouse arrested for assault.
  B) Refuse to permit the spouse to visit with the client.
  C) Call security to have the spouse removed.
  D) Ask the client if there is anything that is needed at this time.

Question 2

A client is complaining of pain in the lower-left quadrant of the abdomen. The nurse prepares to percuss the abdomen and notes that the client has a great deal of hair on the lower abdomen.
 
  Which action by the nurse is appropriate prior to percussing the client's abdomen?
  A) Moistening the abdominal hair
  B) Documenting that the client has hirsutism
  C) Cutting the client's hair over the entire abdomen
  D) Discontinuing the use of percussion, palpate the abdomen only.

[triiciiaa]

Answer to Question 1

Answer: D

The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and their family members. The nurse should ask the client if there is anything that is needed at this time. The nurse should not refuse to let the spouse visit unless it is the client's wish to do so. The nurse should not contact security or the police.

Answer to Question 2

Answer: A

If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.