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: OCD behaviors are not typically aimed at preventing aggressive and impulsive behaviors but are a response to anxiety-provoking obsessions.

Choice B reason: The repetitive behaviors associated with OCD, such as cleaning, are not intended to manipulate others but are compulsions that the individual feels driven to perform.

Choice C reason: The goal of repetitive cleaning in OCD is not to decrease social interaction time but to alleviate the distress caused by obsessive thoughts, often related to cleanliness or contamination.

Choice D reason: Repetitive cleaning in OCD is a compulsion that aims to decrease the anxiety caused by obsessive thoughts. It is a way for the individual to manage their anxiety and gain a sense of control over their environment.

A. Cardiac monitor B. Blood pressure monitor C. Portable x-ray machine D. Electroencephalogram (EEG) monitor E. Ophthalmoscope

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A cardiac monitor is essential during ECT to monitor the heart's electrical activity, as the procedure can affect heart rate and rhythm.

Choice B reason: A blood pressure monitor is necessary to track the client's blood pressure throughout the procedure, as ECT can cause fluctuations in blood pressure.

Choice C reason: A portable x-ray machine is not typically required in the setup for ECT.

Choice D reason: An EEG monitor is used during ECT to record the electrical activity of the brain, which is crucial for assessing the seizure activity induced by the treatment.

Choice E reason: An ophthalmoscope is not used during ECT; it is an instrument for examining the interior structures of the eye.

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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

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and observes that the client engages in constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

Correct Answer is D

Explanation

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.)

Correct Answer is ["A","B","D"]

Explanation

The nurse is talking with a client diagnosed with histrionic personality disorder. Which statement made by the client does the nurse identify as correlating with this diagnosis?

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

Which of the following statements is associated with a client's child experiencing hair loss?

The nurse is planning the care of a client with bipolar disorder and addiction to heroin who is in a rehabilitation facility. Which outcomes will the nurse assign in the immediate phase after withdrawal symptoms are over? (Select all that apply.)

Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which techniques will the nurse use to foster trust? Select all that apply.