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: For a client with Alzheimer's disease, it is beneficial to talk them through tasks one step at a time to help maintain their cognitive function and independence for as long as possible. This approach can reduce confusion and frustration.
Choice B reason: While rotating caregivers might provide variety, it can be confusing for a client with Alzheimer's disease. Consistency in caregivers can help establish a routine and sense of familiarity, which is comforting and can reduce anxiety.
Choice C reason: A consistent daily activity schedule is crucial for clients with Alzheimer's disease. It helps to maintain a sense of normalcy and can reduce stress and confusion. Changing the schedule daily could lead to increased anxiety and disorientation.
Choice D reason: Allowing ample time for activities is important as rushing can cause stress and agitation in clients with Alzheimer's disease. They often require more time to process information and complete tasks due to cognitive impairments.
Correct Answer is D
Explanation
Choice A reason: This statement does not necessarily suggest a somatoform disorder, as it expresses hope for a medical diagnosis.
Choice B reason: Mentioning overexertion could be a logical explanation for pain and does not directly indicate a somatoform disorder.
Choice C reason: Expressing difficulty with life changes does not specifically suggest a somatoform disorder, which is characterized by physical symptoms without a medical cause.
Choice D reason: This statement suggests that the pain may be linked to psychological factors, such as stress from losing a job, which is characteristic of a somatoform disorder.
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