A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.

Have two nurses present at all times to perform all care and procedures.

Perform continuous assessment of the client's anxiety level.

Allow the client to perform all care independently and without assistance.

Ask for permission before performing any intervention that requires touch.

Have security present outside of the client's room to prevent anyone from coming in.

Answer and Explanation

Correct Answer : B,D

Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.

Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.

Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.

Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.

Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.

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Correct Answer is D

Explanation

Choice A reason: Separating finances is a practical step but does not address the underlying issues of alcoholism as a family illness.

Choice B reason: Attending Al-Anon meetings is a positive step towards understanding and coping with the effects of a family member's alcoholism.

Choice C reason: Allowing the client to face the consequences of their actions can be part of setting boundaries, which is important in dealing with alcoholism.

Choice D reason: Calling in sick for the client enables the behavior and prevents the client from facing the natural consequences of their alcoholism, indicating a need for further education on the illness.

A. Acrophobia B. Xenophobia C. Agoraphobia D. Mysophobia

Correct Answer is C

Explanation

Choice A reason: Acrophobia is the fear of heights, which is not indicated by the client's fear of being outdoors alone.

Choice B reason: Xenophobia is the fear of strangers or foreigners, which does not align with the client's described fear.

Choice C reason: Agoraphobia is the fear of open spaces or being in crowded, public places like markets. It also includes the fear of leaving a safe place, such as home, which aligns with the client's symptoms.

Choice D reason: Mysophobia is the fear of germs, which is not related to the fear of being outdoors alone.

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A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is leading a family therapy group with a client addicted to alcohol. Which statement made by the spouse indicates the need for additional education regarding alcoholism as a family illness?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

When a community health nurse arrives at the home of a client diagnosed with Bulimia Nervosa and finds the client unconscious on the floor with a history of using laxatives, what is the most likely cause of the client's current state?

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A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.)

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