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: Bulimia Nervosa often involves behaviors such as excessive laxative use, which can lead to severe electrolyte imbalances, potentially causing unconsciousness.

Choice B reason: While a sudden cardiac event is possible, it is less likely to be directly related to the history of Bulimia Nervosa and laxative use.

Choice C reason: There is no indication that an accidental fall occurred, and it would not be directly related to the history of laxative use.

Choice D reason: Without further information, it is speculative to attribute the unconsciousness to a reaction to another medication.

A. The client is attending all therapy sessions and utilizing the services provided. B. The client states that they feel the issues have been resolved and no longer need to come. C. The client is sharing feelings and emotions with the nurse. D. The client is answering questions related to the plan of care.

Correct Answer is C

Explanation

Choice A reason: Attending all therapy sessions and utilizing services indicates cooperation but does not specifically reflect the identification phase, which is characterized by deeper emotional connections.

Choice B reason: Stating that issues have been resolved and no longer needing to come may suggest a conclusion to the therapeutic relationship rather than the development of the identification phase.

Choice C reason: Sharing feelings and emotions with the nurse is indicative of the identification phase, where the client starts to see the nurse as a supportive figure and begins to identify with them.

Choice D reason: Answering questions related to the plan of care shows engagement but does not necessarily indicate the identification phase's emotional connection.

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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

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?

Correct Answer is A

Explanation

The nurse has established a therapeutic relationship with a client. Which behaviors indicate that the client has entered into the identification phase of the nurse-client relationship?

Correct Answer is C

Explanation

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

The nurse is providing education for a client to improve mental and emotional health and influence the client's response to illness. Which statement made by the client indicates that the education is effective? (Select all that apply.)

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

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?

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.)