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 A

Explanation

Choice A reason: Dialectical behavior therapy (DBT) is a well-established treatment for borderline personality disorder, focusing on skills like mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

Choice B reason: While behavioral contracts can be part of treatment, they are not as central or evidence-based as DBT for borderline personality disorder.

Choice C reason: Bibliotherapy can be a supportive tool but is not a primary intervention for the complex needs of someone with borderline personality disorder.

Choice D reason: A safety plan is important, especially if there are concerns about self-harm or suicidal ideation, but it is not a comprehensive treatment approach like DBT.

A. A client who is unable to provide basic needs when resources are available. B. A client who acts only in their own interests. C. A client who is gravely disabled. D. A client with a severe intellectual developmental disorder. E. A client who is nonadherent to their medication regimen.

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

Explanation

Choice A reason: A client unable to provide for basic needs, despite having resources, may lack the capacity to make informed decisions, necessitating a proxy decision-maker.

Choice B reason: Acting in one's own interest does not necessarily indicate an inability to make informed decisions about care.

Choice C reason: A gravely disabled client may not be able to comprehend the nature of their condition or the consequences of medical decisions, thus requiring assistance.

Choice D reason: Clients with severe intellectual developmental disorders often require a legal guardian to make healthcare decisions on their behalf.

Choice E reason: Nonadherence to medication could be due to various factors, including lack of understanding of the treatment plan, indicating the need for a decision-maker.

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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 nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

Correct Answer is A

Explanation

In the inpatient behavioral health unit, which clients require someone to make decisions regarding their medical and psychiatric care in their best interest? Select all that apply.

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

Explanation

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client expresses discomfort with a male nurse as her caregiver. Which response should the nurse manager provide?

The nurse is attempting to develop empathy for a client but is not completely feeling empathetic. Which factor might be hindering the nurse from developing empathy for this client?

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

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.)