A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?
Invite a family member to be present for the nursing history.
Provide basic wound care for obvious physical injuries.
Be direct and honest when speaking with the client.
Probe the client to offer a factual account of the abuse.
The Correct Answer is C
Rationale for A: Inviting a family member to be present may hinder communication, especially if the family member is involved in the abuse or the client feels unsafe speaking in their presence. Privacy is crucial for encouraging open communication.
Rationale for B: Providing basic wound care is important for physical injuries, but it does not directly address promoting communication. The nurse should focus on creating a safe environment for the client to talk.
Rationale for C: Being direct and honest when speaking with the client promotes trust and open communication. Clients who are suspected of being abused may be fearful or reluctant to share information, so clear, respectful communication helps create a supportive environment.
Rationale for D: Probing the client for a factual account of the abuse may make the client feel pressured or overwhelmed. The nurse should allow the client to share information at their own pace without feeling forced to disclose details.
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Related Questions
Correct Answer is B
Explanation
A. While assessing coping skills is essential, in a crisis situation, determining immediate risks to the client's safety takes precedence.
B. Assessing for psychotic thinking is crucial to address immediate safety concerns. Psychosis can present significant risks and requires immediate attention.
C. While support systems are important for long-term recovery, determining immediate safety concerns is a priority.
D. Identifying the cause of the crisis is relevant but may not be the immediate priority when the client's safety is at risk due to potential psychotic thinking.
Correct Answer is ["C","D"]
Explanation
A. Discussing the client's suicide plan might inadvertently trigger or worsen suicidal thoughts and is not recommended.
B. Restricting visitors might hinder the client's social support system, which is essential in managing depression.
C. Reinforcing statements regarding a will to live and realistic plans for the future promotes hope and positive thinking.
D. Encouraging the client to discuss thoughts and feelings about wanting to die allows for expression and processing of emotions.
E. Limiting time allowed to play video games might be part of a broader plan, but it's not directly addressing depression and might not be as impactful as other interventions.
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