Practice Question
A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck. When asked what happened she states, "l walked into a door." What are the most appropriate interventions by the nurse? (Select All that Apply.)
Answer Choices:
Correct Answer:
Maintain a calm, caring, professional demeanor
Rationale:
Maintain a calm, caring, professional demeanor
🔷 A trauma‑informed approach lowers the client’s anxiety and hyperarousal, creating the psychological safety needed for disclosure.
🔷 A nonjudgmental, steady tone and open body language communicate respect and belief, which counters shame and self‑blame common after assault.
🔷 Calm professionalism helps the nurse build rapport quickly, enabling more accurate assessment of injury pattern, timeline, and risk.
🔷 It also supports autonomy, allowing the teen to make informed choices about resources (advocacy, SANE exam, safety planning).
🔷 This demeanor reduces the chance of retraumatization, aligning with best practices for trauma‑ and violence‑informed care.
Ask the teen if she feels safe
🔷 A direct, compassionate safety question assesses imminent danger and guides the urgency of interventions (e.g., secure environment, escalation).
🔷 It opens the door to a lethality screen (recent strangulation, threats, weapons, escalating violence), which predicts high‑risk harm.
🔷 Determining safety informs whether the nurse should initiate immediate safety measures and involve appropriate services per policy.
🔷 The response shapes individualized safety planning (safe contacts, code words, emergency numbers, options for emergency shelter).
🔷 Documenting the client’s own words about safety provides clear, defensible clinical evidence and supports continuity of care.
Interview the client privately
🔷 Private interviewing removes potential coercion or surveillance by the accompanying person, increasing the likelihood of truthful disclosure.
🔷 It protects confidentiality and reduces risk of retaliation, which can occur if controlling partners hear the teen’s account.
🔷 Privacy allows the nurse to use validated screening tools (e.g., HITS) and complete a HEADSSS psychosocial assessment safely.
🔷 In a private setting the nurse can review options and rights (medical care, evidence collection per policy, advocacy) without pressure.
🔷 It also enables meticulous injury documentation (location, size, photos per protocol) to support medical and future legal needs.
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This question is from Custom: NUR209 Final Assessment Su2. 2025 which contains 61 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 5