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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Free Nursing Study Resources

Correct Answer is ["0.6"]

Explanation

Step 1: Determine the dosage available per mL.

Available dosage is 8 mg in 0.4 mL.
Calculation: 8 mg ÷ 0.4 mL = 20 mg/mL.
Result: 20 mg/mL.

Step 2: Calculate the volume needed for 12 mg.

Required dosage is 12 mg.
Calculation: 12 mg ÷ 20 mg/mL = 0.6 mL.
Result: 0.6 mL.

So, the nurse should administer 0.6 mL of methylnaltrexone.

A. "You can reduce your anger by hitting a punching bag." B. "You need to learn how to be less assertive in your communications." C. "You need to learn to suppress these angry feelings." D. "Anger is a normal feeling, and you can use it to solve problems

Correct Answer is D

Explanation

Option D is the most helpful statement when working with a client who has frequent angry outbursts. It acknowledges that anger is a normal emotion that everyone experiences at times. Additionally, it provides a positive perspective on anger, suggesting that it can be used constructively to solve problems.

Anger itself is not a negative emotion; it becomes problematic when it is expressed inappropriately or disruptively. By validating the client's feelings and reframing anger as a potential tool for problem-solving, the nurse can help the client explore healthier ways to cope with and express their emotions.

Options A, B, and C are not as helpful in this situation:

A. "You can reduce your anger by hitting a punching bag." - While physical activity can help release pent-up emotions, this statement focuses solely on a physical outlet for anger and does not address the underlying issues causing the frequent angry outbursts.

B. "You need to learn how to be less assertive in your communications." - This statement suggests that the client's assertiveness is the problem, which may not be the case. Instead, the nurse should focus on helping the client develop healthier ways to express their emotions and communicate effectively.

C. "You need to learn to suppress these angry feelings." - Encouraging the suppression of emotions is not a healthy coping mechanism. Suppressing anger can lead to increased stress and may result in more intense outbursts later on. The nurse should help the client learn constructive ways to manage and express their anger.

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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

Correct Answer is ["0.6"]

Explanation

A nurse is working with a client who has frequent angry outbursts which is disrupting life at home. Which statement by the nurse is most helpful when working with this client?

Correct Answer is D

Explanation

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

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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?

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

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.)

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.)