The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Correct Answer is A

Explanation

A. Establishing trust by providing a calm, safe environment is crucial for clients with agoraphobia, as it lays the foundation for effective therapeutic interventions and supports the client's sense of safety and security.
B. Encouraging deep breathing is a helpful coping strategy, but it may not be the highest priority compared to establishing trust and safety.
C. Progressively exposing the client to larger crowds is part of desensitization therapy, but it should be done gradually and only after trust and rapport have been established.
D. Encouraging substitution of positive thoughts for negative ones is a valuable cognitivebehavioral technique, but it may be more effective once the client feels safe and supported in the therapeutic environment.

A. Suicide B. Depression C. Post-traumatic stress disorder D. Becoming an abuser E. Human immunodeficiency virus F. Chlamydia

Correct Answer is ["B","C"]

Explanation

A. Suicide is a potential risk following sexual assault due to the emotional trauma that can ensue; however, it is not specific to males and therefore not the best answer in this context.
B. Depression is a common sequela of sexual assault among survivors due to the significant psychological impact of the trauma, which can lead to feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed.
C. Post-traumatic stress disorder (PTSD) is another frequent outcome of sexual assault, characterized by persistent mental and emotional stress as a result of injury or severe psychological shock. PTSD can manifest in nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event.
D. Becoming an abuser is a potential outcome for some survivors of sexual assault, but it is not one of the most common sequelae and is not supported by the literature as a primary risk for male survivors.
E. Human immunodeficiency virus (HIV) is a risk in cases of sexual assault where the transmission of bodily fluids occurs, but it is not a psychological sequela and thus not relevant to the question.
F. Chlamydia, like HIV, is a sexually transmitted infection that can be a risk in cases of sexual assault involving transmission of bodily fluids. However, it is not a psychological sequela and is not specific to the male gender in the context of sexual assault risk factors.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Correct Answer is A

Explanation

Correct Answer is ["B","C"]

Explanation

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?