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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:

Informed consent is a critical component of many medical treatments, including ECT. It involves the patient's understanding and agreement to the procedure after being fully informed of the risks, benefits, and alternatives. Cognitive deficits can impair a patient's ability to provide informed consent, but they do not automatically waive the requirement for such consent. In fact, additional safeguards are often put in place to protect the rights of individuals with cognitive impairments.

Choice B reason:

ECT is a medical procedure that requires informed consent due to the potential risks and side effects associated with it. If a client has cognitive deficits severe enough to impact their decision-making capacity, they may not be able to provide informed consent. In such cases, treatment options would need to be reconsidered, and alternative methods of obtaining consent, such as through a legal guardian or a court order, might be necessary.

Choice C reason:

While it is true that ECT is considered an effective treatment for severe depression and suicidality, the decision to use ECT should not be based solely on these criteria². The ability of the client to understand and consent to the treatment is also a crucial factor. Therefore, the extremity of the client's suicidal ideation alone does not make ECT automatically the appropriate option without considering the consent issue.

Choice D reason:

ECT is indeed an alternative treatment when antidepressant medications have been ineffective, especially in cases of severe depression and suicidality². However, the effectiveness of ECT does not negate the need for informed consent. The client's cognitive ability to provide consent remains a determining factor in the feasibility of ECT as a treatment option.

A. "Did your husband say something to upset you?" B. "Tell me what is concerning you." C. "Your husband is making really good progress!" D. "Did something bad happen to your husband?"

Correct Answer is B

Explanation

The correct answer is: "Tell me what is concerning you."

Choice A reason:

Asking "Did your husband say something to upset you?" may seem accusatory and could lead the spouse to feel defensive. It does not open a dialogue for the spouse to express their concerns freely and can be perceived as leading the conversation in a negative direction.

Choice B reason:

"Tell me what is concerning you." is an open-ended statement that invites the spouse to share their feelings and concerns. It demonstrates empathy and active listening, which are key components of therapeutic communication. This response encourages the spouse to elaborate on their feelings and fosters a supportive environment.

Choice C reason:

Saying "Your husband is making really good progress!" is reassuring, but it does not address the spouse's current emotional state or concerns. It may come across as dismissive of the spouse's feelings and does not encourage further discussion about their worries.

Choice D reason:

Asking "Did something bad happen to your husband?" can increase anxiety and assumes a negative event has occurred. It is not a therapeutic response because it does not provide comfort or support to the spouse in a stressful situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 with cognitive deficits is extremely suicidal and has not responded to antidepressants. The treatment team is considering electroconvulsive therapy (ECT). Which client information would impact the feasibility of this treatment option?

Correct Answer is B

Explanation

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?

Correct Answer is B

Explanation

The nurse maintains a therapeutic relationship with several clients on the behavioral health unit. Which characteristics will be most important for the nurse to foster to maintain these relationships? Select all that apply.

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

A nurse is conducting a group session in the behavioral health unit for three clients on the topic of anxiety. The nurse determines that the session was successful based on which statement by the clients?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.