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 The client is quiet and withdrawn.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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clinical algorithms help in standardizing certain processes but might not specifically integrate evidence-based practice guidelines for evaluating therapy plans.
B. Clinical practice guidelines offer evidence-based recommendations, aiding healthcare providers in decision-making for specific conditions or treatments.
C. While the internet may provide information, it might lack the vetting and credibility of evidence-based practice guidelines provided by reputable sources.
D. Clinical pathways provide a structured approach to care delivery but might not inherently integrate evidence-based practice guidelines unless these are explicitly incorporated into the pathway.
Correct Answer is B
Explanation
A. Intervening during self-harm is more related to beneficence (preventing harm) rather than autonomy (respecting the patient's right to make decisions).
B. Autonomy involves respecting a patient's right to make decisions about their care, including discussing alternatives for treatment.
C. Staying with an anxious patient is supportive but doesn't specifically address the principle of autonomy.
D. Restricting patients who are fighting is more related to safety and order within the unit, not necessarily autonomy.
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