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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Weight gain is indeed a known side effect of lithium treatment, and acknowledging this can validate the client's experience.

Choice B reason: This response could be perceived as blaming and does not acknowledge that weight gain can be a side effect of lithium.

Choice C reason: This statement is misleading as weight gain can occur beyond the first month of treatment with lithium.

Choice D reason: This statement is incorrect as weight loss is not the typical pattern associated with lithium; weight gain is more common.

A. Support systems B. Physical health C. Mental health support D. Alcohol consumption E. Feelings of self-worth F. Family history G. Access to lethal means

Correct Answer is ["A","B","C","E","F","G"]

Explanation

Choice A reason: Support systems are crucial for emotional and practical support, especially when dealing with mental health issues.

Choice B reason: Physical health can significantly impact mental health, and vice versa; it's important to consider the client's overall well-being.

Choice C reason: Mental health support, such as therapy or support groups, is essential for someone struggling with the effectiveness of their medication.

Choice D reason: While alcohol consumption can affect mental health, it is not mentioned in the client's statement and therefore cannot be assumed.

Choice E reason: Feelings of self-worth are directly related to mental health and can influence the client's perspective on their value and the burden they perceive themselves to be to others.

Choice F reason: Family history can provide insight into potential hereditary patterns of mental health issues and the client's support network.

Choice G reason: Access to lethal means is a critical safety concern, especially for clients expressing feelings of worthlessness or experiencing severe depression.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client began taking lithium for the treatment of bipolar disorder approximately one month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","E","F","G"]

Explanation

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

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A nurse is educating the family of an adolescent client with anorexia nervosa about the issues surrounding this eating disorder. Which statement made by the parent indicates that the education is effective?

The nurse is talking with a client diagnosed with histrionic personality disorder. Which statement made by the client does the nurse identify as correlating with this diagnosis?