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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

Correct Answer is ["260"]

Explanation

Step 1: Convert ½ cup of juice to mL. 1 cup = 240 mL ½ cup = 240 mL ÷ 2 = 120 mL Result: 120 mL

Step 2: Convert 3 oz of gelatin to mL. 1 oz = 30 mL 3 oz = 3 × 30 mL = 90 mL Result: 90 mL

Step 3: Convert 1 oz of an ice pop to mL. 1 oz = 30 mL 1 oz = 1 × 30 mL = 30 mL Result: 30 mL

Step 4: Ginger ale is already in mL. Result: 20 mL

Step 5: Add all the mL values together. 120 mL + 90 mL + 30 mL + 20 mL = 260 mL Result: 260 mL

The nurse should record the child’s fluid intake as 260 mL.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Correct Answer is A

Explanation

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Correct Answer is ["260"]

Explanation

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The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

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.)