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 patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies having had the desire to kill her husband and has no history of violence. The nurse should document in the medical record that: (Select all that apply.) a. signs of high anxiety and chronic stress are present.
b. the patient relies on the perpetrator for basic needs.
c. the patient is isolated from individual and community support.
d. suicide risk is high and merits inpatient admission.
e. the immediate risk of revenge homicide is low.
f. a safety plan should be constructed before discharge.
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