The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply.
(Select All that Apply.)
Prior to performing any intervention that requires touch, the nurse will ask permission.
Have the client perform all care independently and without assistance.
Have two nurses present at all times in which to perform all care and procedures.
The nurse will perform a continuous assessment of the client's anxiety level.
Have security present outside of the client's room to prevent anyone from coming in.
Correct Answer : A,D,E
The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:
A. Prior to performing any intervention that requires touch, the nurse will ask permission.
This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.
D. The nurse will perform a continuous assessment of the client's anxiety level.
Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.
E. Have security present outside of the client's room to prevent anyone from coming in.
Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.
It is not appropriate to:
B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.
C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Aggression is a behavior characterized by hostility, anger, or violent actions toward others or objects. In the scenario described in option B, the client demonstrates aggressive behavior by stomping away from the nurses' station and grabbing a pool cue from another client. This behavior indicates hostility and potential violence towards others, which is a clear example of aggression.
Options A, C, and D do not describe aggressive behavior. Option A describes a client expressing sadness and seeking comfort by hugging a pillow and sobbing. Option C describes a client expressing anger verbally but not exhibiting aggression. Option D describes a client refusing to take medication, which may not necessarily involve aggressive behavior.
Correct Answer is D
Explanation
The statement, "I will find a support group to help me through this," indicates that the client's coping skills are adequate. Seeking support from others who have experienced a similar loss can be an effective way to cope with feelings of loneliness and vulnerability after the death of a spouse. Support groups provide a safe and understanding environment where individuals can share their experiences, feelings, and struggles, and receive emotional support from others who can relate to their situation.
Option A suggests an overconfidence in coping skills and may not fully acknowledge the need for external support during a challenging time.
Option B indicates a sense of feeling abandoned, which could be a sign of struggling coping skills.
Option C suggests confusion and difficulty accepting the loss, which may indicate inadequate coping skills at the moment.
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