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 ["B","D","E"]

Explanation

Choice A reason: Sharing personal feelings openly with the client can blur the professional boundaries necessary for a therapeutic relationship and is not typically encouraged.

Choice B reason: Establishing boundaries is crucial in maintaining a professional and therapeutic relationship, ensuring that both the nurse and client understand the limits and expectations of their interactions.

Choice C reason: While offering advice can be part of the therapeutic process, it is more important for the nurse to guide clients in finding their own solutions rather than providing direct advice.

Choice D reason: A therapeutic relationship should be professional and not based on personal feelings. The nurse's concern should be on the client's well-being rather than being liked.

Choice E reason: Maintaining a client focus at all times ensures that the care provided is centered on the client's needs, which is essential in a therapeutic relationship.

A. "Where do you keep your gun?" B. "Are you thinking about hurting yourself or someone else?" C. "Have you thought about how you would hurt yourself?" D. "Can you tell me your feelings about dying?" E. "Have you told your psychiatrist you feel like dying?"

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

Explanation

Choice A reason: While it’s important to assess access to lethal means, this question is too specific and assumes the client owns a gun. A more appropriate question might be, “Do you have access to any means to harm yourself?”

Choice B reason: Inquiring about thoughts of self-harm or harming others is a direct question that assesses suicidal ideation and intent, which is essential for determining immediate risk.

Choice C reason: Understanding if the client has specific plans for self-harm can help gauge the immediacy and seriousness of the suicide risk.

Choice D reason: Discussing feelings about dying can provide insight into the client's emotional state and potential risk for suicide.

Choice E reason: This question is important but it should not replace direct questions about the client’s current thoughts and feelings. It’s possible for a client to deny feelings of suicidality to their psychiatrist while still experiencing them.

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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 maintains a therapeutic relationship with several clients on the behavioral health unit. Which characteristics will be most important for the nurse to foster to maintain these relationships? Select all that apply.

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

Explanation

The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

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

Explanation

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

The nurse is providing education to a client regarding a new prescription for lithium carbonate. Which statement by the client indicates the need for additional education?

The nurse is planning an approach that will be most effective in developing a therapeutic relationship with a client. Which disorder(s) will the nurse best employ a matter-of-fact approach with the client? (Select all that apply.)

A client is seeking counseling due to difficulty coping with being a victim of a violent attack 16 months ago. Which elements will the nurse assess for when determining the major components of posttraumatic stress disorder (PTSD)? (Select all that apply.)

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?

A college student has been diagnosed with Generalized Anxiety Disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? Select all that apply.

A nurse is conducting a group session in the behavioral health unit for three clients on the topic of anxiety. The nurse determines that the session was successful based on which statement by the clients?

The nurse is performing an assessment for a young adolescent and observes a lack of hair on the eyebrows and the hairline. Which statement made by the parent demonstrates an understanding of the type of hair loss the child is experiencing?