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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Seclusion may be considered for an adult client following a suicide attempt if they are a danger to themselves or others, but it must be used with caution and as a last resort.
Choice B reason: Seclusion could be used for a school-age client who attempts to repeatedly bite staff as a means to prevent harm to others.
Choice C reason: An adolescent client who throws objects at other clients may also be secluded to prevent harm to others, but again, it should be a last resort.
Choice D reason: Seclusion is contraindicated for an older adult client who is manic and crying due to overstimulation as it may exacerbate their distress and agitation.
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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