# A nurse is assessing a 45-year-old male client who presents to a primary care clinic with unexplained weight loss and fatigue. The client's spouse accompanies him and answers most questions directed to the client. Which assessment finding would be the MOST indicative of elder abuse?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543459  
> language: ko  
> subject: Mental Health

## 문제

A nurse is assessing a 45-year-old male client who presents to a primary care clinic with unexplained weight loss and fatigue. The client's spouse accompanies him and answers most questions directed to the client. Which assessment finding would be the MOST indicative of elder abuse?

## 보기

1. The client describes tripping over a rug and falling down stairs at home two days ago
2. The client has bruises on his shins and forearms that match common accidental injury sites
3. The client provides inconsistent explanations for his injuries when questioned separately from his partner **✔ 정답**
4. The client appears anxious and withdrawn during the assessment, avoiding eye contact

**정답: 3**

## 해설

Inconsistent explanations when questioned separately from the partner is most indicative of IPV as victims often give rehearsed stories with the abuser but may reveal truth alone. Other options like reported falls, bruise patterns, or anxiety are less specific indicators.

## 심화 해설

Clinical Judgment
The core of this question is identifying the most decisive and objective cue among several warning signs in the 'Recognizing Cues' stage of the Clinical Judgment Measurement Model (CJMM). Bruises in various stages of healing, the presence of a controlling partner, and anxious behavior are all important cues suggesting IPV (Intimate Partner Violence). However, the strongest indicator is that the client's explanation of injuries is **inconsistent** when questioned separately from the partner. This is because a victim may give a prepared story in front of the abuser but may offer a different account or hint at the truth in a safe environment. Other options raise the likelihood of IPV, but they are not as direct and objective as inconsistent explanations.

Memory Tip:
Remember to **S**eparate, **A**sk, and **L**isten for **I**nconsistencies. This is the **SALI** principle for IPV assessment.

KR vs US:
In Korea, mandatory reporting of domestic violence applies when the injury level is 'bodily injury' or higher, whereas a U.S. nurse must initiate internal reporting and safety planning based on suspicion alone. Additionally, in Korean culture, such matters are often considered 'family affairs' or are concealed due to shame, requiring a more careful and culturally sensitive approach than in the U.S.

## 임상 시나리오

Clinical Practice Guide
When assessing a client suspected of IPV, you must interview them privately, separated from their partner. It is good to start by saying, "I routinely ask all patients about partner violence." Maintain a non-judgmental attitude and discuss a safety plan, prioritizing the client's safety above all.

Caution:
In SATA (Select All That Apply) questions asking for "signs of IPV," 'bruises in various stages of healing,' 'partner's controlling behavior (answering for them),' 'anxiety/withdrawal,' and 'inconsistent explanations for injuries' can **all** be correct answers. However, beware of the trap in questions like this one that ask for the "**MOST** indicative" sign: you should select 'inconsistent explanations when questioned separately from the partner'.

## 핵심 개념

- **Intimate Partner Violence** — Physical, sexual, emotional, psychological, or economic abuse committed by a current or former spouse, dating partner, or sexual partner in an intimate relationship.
- **Power and Control Dynamics** — A pattern of behavior used by an abuser to exert power and maintain control over a victim in an abusive relationship. An example of this is when a partner answers on behalf of the client.
- **Safety Planning** — A personalized, practical plan prepared in advance by an IPV victim to leave an abusive situation or minimize risk. It is a key intervention role for nurses.
- **Mandatory Reporting** — Duty of medical personnel to report domestic violence under specific conditions (e.g., use of a specific weapon, serious injury) as required by law. State laws may vary.
- **Therapeutic Communication** — A communication technique that explores and supports the client's feelings and experiences with a nonjudgmental and empathetic attitude. It is essential when assessing IPV.

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