A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?

Display disapproval toward the perpetrator.

Probe the client to offer a factual account of the abuse.

Be direct and honest when communicating with the client.

Invite a family member to be present for the nursing history.

Answer and Explanation

The Correct Answer is C

"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.

Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting

Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting

Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.

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Correct Answer is B

Explanation

The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.

Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,

choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.

A. Allow the client to pace alone until physically tired. B. Walk with the client at a gradually slowing pace. C. Ask a small group of other clients to walk with the client. D. Calmly instruct the client to stop pacing and sit in the dayroom.

Correct Answer is B

Explanation

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

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A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care?

Correct Answer is B

Explanation

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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