A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply.)
Plan an escape route to use if the abuser blocks the main exit.
Have a bag ready that has extra clothes for self and children.
Give the abuser the location of where you will be staying.
Establish a signal with family and friends to signify violence.
Purchase a gun to use for protection.
Correct Answer : A,B,D
Choice A reason: Planning alternate escape routes is a core part of safety planning, ensuring the victim can exit safely even if blocked.
Choice B reason: Having an emergency bag ready allows quick departure and reduces risk of having to return to the abuser’s home.
Choice C reason: Giving the abuser information about location compromises safety and places the victim at greater risk.
Choice D reason: Establishing a signal with trusted individuals ensures the victim can get help quickly if violence escalates.
Choice E reason: Encouraging firearm purchase is not an appropriate nursing intervention due to safety risks and escalation potential. Safer protective strategies should be emphasized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The M’Naghten Rule requires proof that, due to mental illness, the person did not understand the nature of the act or could not distinguish right from wrong at the time of the offense. This is the key standard used in many jurisdictions for insanity defenses.
Choice B reason: Having a history of mental illness alone is not sufficient; the rule focuses on the client’s mental state during the offense, not prior diagnoses.
Choice C reason: Being driven by uncontrollable impulses is not part of the M’Naghten criteria. This falls more under the “irresistible impulse” test, which is separate.
Choice D reason: Intoxication, even if it impairs judgment, does not qualify under the M’Naghten Rule. Voluntary substance use generally excludes insanity defenses.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Avoiding judgmental remarks supports therapeutic rapport and prevents worsening anxiety or defensiveness.
Choice B reason: Teaching coping strategies like thought stopping helps the client begin to manage obsessive behaviors more effectively.
Choice C reason: Identifying triggers for obsessive behaviors allows the nurse and client to develop strategies for prevention and management.
Choice D reason: Removing magazines to prevent counting avoids addressing the underlying compulsion and may increase anxiety. This approach is not appropriate in the initial care plan.
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