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
Explanation: This statement is highly inappropriate and victim-blaming. It implies that the client's clothing choices are somehow responsible for the sexual assault they experienced. Victim-blaming is never acceptable and can be harmful to the survivor, making them feel ashamed and responsible for the actions of the perpetrator. As healthcare professionals, nurses should always respond to victims of sexual assault with empathy, compassion, and without judgment.
The other statements (A, C, and D) are all appropriate and acknowledge the seriousness of the situation:
A. "We need to offer the client emotional support especially when obtaining specimens." Explanation: This statement recognizes the need for emotional support during the examination process, which can be distressing for the survivor. Providing emotional support and ensuring the client's comfort and consent during the examination are crucial aspects of caring for a sexual assault survivor.
C. "The client feels like they won't be believed since there was alcohol involved during the date." Explanation: This statement highlights the survivor's feelings and concerns about being believed due to alcohol involvement. It emphasizes the importance of creating a safe and non-judgmental environment for the client, where they can share their experience and receive appropriate care and support.
D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away." Explanation: This statement indicates an understanding of the importance of consent and acknowledges that the client's clear expression of refusal should have been respected. Understanding and respecting consent is crucial when discussing cases of sexual assault.
Correct Answer is C
Explanation
In cases of elder abuse by family members, the emotional bond and dependency on the abusers can create a significant barrier for the older adult to report the abuse. The client may fear damaging the relationship with their adult children or causing harm to the family dynamics. This emotional closeness and loyalty to the family may prevent the client from disclosing the abuse and seeking help.
Option A is not correct because laws do provide protection against elder abuse, including abuse by family members. Many jurisdictions have specific laws and protective services in place to address elder abuse.
Option B is not correct because financial resources, while important, are not the primary reason why the client has not reported the abuse. The emotional bond with the abusers is a more significant factor.
Option D is not correct because abuse does not need to involve physical harm to be considered abuse. Emotional, financial, and other forms of abuse can also be harmful and should be reported and addressed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.