A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.
Have two nurses present at all times to perform all care and procedures.
Perform continuous assessment of the client's anxiety level.
Allow the client to perform all care independently and without assistance.
Ask for permission before performing any intervention that requires touch.
Have security present outside of the client's room to prevent anyone from coming in.
Correct Answer : B,D
Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.
Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.
Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.
Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.
Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Focusing conversations on nutritious food can be positive, but it does not directly indicate a change in behavior related to bulimia nervosa.
Choice B reason: Gaining weight may be a positive sign, but it is not sufficient on its own to indicate a behavioral change, as weight can fluctuate for various reasons.
Choice C reason: Demonstrating healthy coping mechanisms that decrease anxiety is a strong indicator of positive behavioral change in a client with bulimia nervosa, as it suggests the client is developing strategies to manage the disorder.
Choice D reason: While verbalizing an understanding of the disorder's etiology is beneficial, it does not necessarily reflect a change in behavior.
Correct Answer is D
Explanation
Choice A reason: The statement about fear being a response to an unknown threat is a common perception, but it does not reflect an understanding of anxiety as a broader concept.
Choice B reason: While anxiety and fear are related, they are not the same; fear is a response to a known or understood threat, whereas anxiety is often more diffuse and not tied to a specific stimulus.
Choice C reason: This statement reflects a negative view of anxiety and does not acknowledge that anxiety can sometimes be a normal and even productive response to stress.
Choice D reason: Recognizing that anxiety is a natural part of life and cannot be completely eliminated reflects an understanding of anxiety as a normal human emotion and is indicative of a successful education session.
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