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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Wernicke-Korsakoff syndrome is a brain and memory disorder that requires immediate treatment. It occurs due to a severe deficiency of thiamine (vitamin B1), which is essential for the brain to convert food into energy.
Choice B reason: There is no evidence suggesting that Wernicke-Korsakoff syndrome is a psychological condition related to stress.
Choice C reason: Wernicke-Korsakoff syndrome is not a genetic disorder; it is caused by a deficiency of vitamin B1, often associated with alcohol abuse or malnutrition.
Choice D reason: It is not an infectious disease; Wernicke-Korsakoff syndrome results from nutritional deficiencies, specifically a lack of thiamine (vitamin B1).
Correct Answer is D
Explanation
Choice A reason: OCD behaviors are not typically aimed at preventing aggressive and impulsive behaviors but are a response to anxiety-provoking obsessions.
Choice B reason: The repetitive behaviors associated with OCD, such as cleaning, are not intended to manipulate others but are compulsions that the individual feels driven to perform.
Choice C reason: The goal of repetitive cleaning in OCD is not to decrease social interaction time but to alleviate the distress caused by obsessive thoughts, often related to cleanliness or contamination.
Choice D reason: Repetitive cleaning in OCD is a compulsion that aims to decrease the anxiety caused by obsessive thoughts. It is a way for the individual to manage their anxiety and gain a sense of control over their environment.
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