A nurse is providing care for a client who experienced sexual assault. Which of the following communication strategies should the nurse use?
Ask open-ended questions about the perpetrator.
Speak softly to the client.
Provide direct eye contact with the client.
Sit next to the client.
The Correct Answer is B
A. While it's important to gather relevant information about the assault, asking open-ended questions about the perpetrator may not be the most appropriate approach initially.
B. Speaking softly helps to convey empathy and can make the client feel more comfortable and less threatened.
C. Direct eye contact can be perceived as intrusive or threatening, especially for individuals who have experienced trauma such as sexual assault.
D. Sitting next to the client rather than directly across can create a more relaxed and less intimidating atmosphere. This approach can help establish a sense of partnership and support, making the client feel more at ease.
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Correct Answer is D
Explanation
D. This response reflects empathy and validates the client's feelings of hopelessness. It acknowledges the client's emotional state and demonstrates active listening. By reflecting back the client's words, the nurse conveys understanding and creates an opportunity for further exploration of the client's feelings and concerns.
A. While addressing medication concerns is important, this response may not fully acknowledge the client's feelings of hopelessness and may come across as dismissive of their emotional distress.
B. This response offers the client an opportunity to speak with a therapist, which can be beneficial for addressing emotional distress and exploring coping strategies. However, it does not directly acknowledge the client's current feelings of hopelessness
C. This response does not address the client's feelings of hopelessness and may not effectively validate their emotional experience.
Correct Answer is C
Explanation
C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.
A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.
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