The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply.
(Select All that Apply.)
Prior to performing any intervention that requires touch, the nurse will ask permission.
Have the client perform all care independently and without assistance.
Have two nurses present at all times in which to perform all care and procedures.
The nurse will perform a continuous assessment of the client's anxiety level.
Have security present outside of the client's room to prevent anyone from coming in.
Correct Answer : A,D,E
The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:
A. Prior to performing any intervention that requires touch, the nurse will ask permission.
This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.
D. The nurse will perform a continuous assessment of the client's anxiety level.
Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.
E. Have security present outside of the client's room to prevent anyone from coming in.
Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.
It is not appropriate to:
B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.
C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.
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Related Questions
Correct Answer is ["A","D","E"]
Explanation
The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:
A. Prior to performing any intervention that requires touch, the nurse will ask permission.
This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.
D. The nurse will perform a continuous assessment of the client's anxiety level.
Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.
E. Have security present outside of the client's room to prevent anyone from coming in.
Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.
It is not appropriate to:
B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.
C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.
Correct Answer is B
Explanation
Explanation: When completing a family assessment for a victim of intimate partner violence, the nurse may identify characteristics of the abuser that contribute to the abusive behavior. Among the options provided, "Needy and possessive of the partner" is the characteristic of the abuser. Abusers often display controlling behavior, which includes possessiveness and excessive need for control over their partners. This possessiveness may manifest as jealousy, isolation, and an attempt to limit the victim's freedom and independence.
A. An ability to feel remorse for the abuse - This characteristic is less likely to be present in an abuser. Abusers often exhibit a lack of remorse for their abusive behavior and may blame the victim or external factors for their actions.
C. An inflated sense of self-esteem - While some abusers may exhibit arrogance and an inflated sense of self-importance, it is not a defining characteristic of all abusers.
D. Encourages the partner to have a life outside the intimate relationship - Abusers typically do the opposite; they often seek to isolate their victims from their support systems and limit their social interactions outside the abusive relationship.
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