A nurse is reviewing the case of a patient with a history of sexual violence trauma. Which nursing interventions should be included in the care plan? (Select all that apply)

Choice A reason: Sudden behavioral changes, like agitation or withdrawal, in dementia patients can indicate abuse. These reflect stress responses, with increased cortisol and amygdala activity disrupting cognitive and emotional regulation. Scientifically, such changes signal potential trauma or fear, requiring investigation to confirm abuse and protect the patient’s psychological and physical well-being.

Choice B reason: A well-kept appearance doesn’t rule out abuse, as abusers may maintain the patient’s hygiene to conceal mistreatment. Scientifically, abuse can occur without visible neglect, as psychological or physical harm may not affect outward appearance. This sign is unreliable for confirming abuse in dementia patients, as it lacks specificity.

Choice C reason: An attentive caregiver may seem positive but can mask controlling or abusive behavior. Scientifically, constant presence could indicate coercive control, not care, potentially increasing the patient’s stress response. This sign is ambiguous, as it doesn’t directly correlate with abuse, requiring further assessment to confirm suspicion in dementia patients.

Choice D reason: Expressing gratitude may reflect fear or manipulation rather than genuine sentiment, especially in dementia, where cognitive impairment affects judgment. Scientifically, abuse can induce learned helplessness, prompting positive statements to avoid harm. This sign is unreliable for confirming abuse, as it may mask underlying psychological trauma.

Choice A reason: Assessing mental status identifies withdrawal’s psychological basis, like depression or PTSD from sexual violence. Scientifically, it evaluates amygdala-driven hyperarousal and cognitive impairments, guiding interventions. This ensures accurate diagnosis, addressing trauma’s neurobiological impact and stabilizing the patient’s mental health for effective recovery.

Choice B reason: Monitoring vital signs tracks physiological stability in withdrawal, which may reflect anxiety or trauma responses. Scientifically, vital sign changes, like elevated heart rate, indicate autonomic arousal or stress hormone spikes. This ensures safety, identifying medical issues and guiding interventions for trauma-related psychological distress.

Choice C reason: Group therapy is premature for withdrawal, as social settings may overwhelm. Scientifically, withdrawal in trauma survivors reflects heightened amygdala activity, making group dynamics stressful. This risks exacerbating anxiety or dissociation, delaying recovery by increasing cortisol-driven stress responses before individual stabilization is achieved.

Choice D reason: Informing of ward rules is administrative, not therapeutic, for withdrawal. Scientifically, it doesn’t address trauma’s neurobiological impact, like cortisol elevation or amygdala hyperactivity. Focusing on rules over psychological needs risks disengagement, delaying interventions critical for stabilizing mental health in sexual violence survivors.

Choice E reason: One-on-one conversation builds trust, encouraging disclosure in withdrawal. Scientifically, this reduces stress by engaging prefrontal cortex processing, countering amygdala-driven fear. It supports emotional regulation, allowing tailored interventions for trauma-related symptoms, fostering recovery in sexual violence survivors by addressing psychological barriers safely.