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7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
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2,240 solutions
3
Rationale: The client in this question should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise, including post-traumatic
stress disorder, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self-esteem, and alcohol and drug abuse. Reddened sclera, a dry rash on the elbows, and flaking of the scalp do not pose an indication of abuse.
2
Rationale: Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment.
Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the
parents and bald spots on the scalp most likely are associated with physical abuse.
1,2,3,5
Rationale: Clients who are victims of abuse or neglect are prone to certain health effects; these effects may be physical, such as bruises, broken bones, chronic fatigue, or involuntary shaking. The victim may also experience mental effects, such as nightmares, anxiety, post-traumatic stress disorder (PTSD), depression, interrupted sleep patterns, and low
self-esteem. Motivation to persevere is not a direct effect and can be a positive characteristic.
3,1,4,2
Rationale: Interventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, educating the client and family about self-care, as well as education on support programs that provide
awareness and emotional support. Also, ensuring that the victim is in a safe environment both in the hospital and when the victim is discharged is a priority. Administering pain medications, and cleaning and dressing wounds should be done first, followed by ensuring environmental safety and providing emotional support.
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1,505 solutions
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
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7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
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121 solutions