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.

Answer and Explanation

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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Correct Answer is A

Explanation

The safety of both the client and others is the top priority in this situation. The client's aggressive behavior poses a significant risk, and immediate action is necessary. Calling for an emergency response from trained personnel, such as security or other staff members experienced in handling aggressive behavior, can help ensure the situation is properly managed and de-escalated in a safe manner.

Option B may not be appropriate in this situation, as trying to engage the client in verbal expression of anger while they are in an agitated and aggressive state can potentially escalate the situation further.

Option C is not recommended, as approaching the client in a confrontational manner may further escalate their anger and aggression.

Option D, while it may be beneficial in a different context and when the client is in a more stable state, is not appropriate when the client is actively engaged in aggressive behavior. The focus at this moment should be on ensuring the immediate safety of everyone involved.

A. Anger B. Acceptance C. Bargaining D. Depression

Correct Answer is C

Explanation

The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of bargaining in the grieving process. During this stage, individuals may try to negotiate or make deals with a higher power or with fate in an attempt to postpone or change the outcome of their situation. In this case, the client is expressing a desire to live long enough to witness the birth of their first grandchild, which represents an attempt to negotiate with their illness and impending death.

It's important for the nurse to be supportive and empathetic during this stage of grieving and to provide emotional support to the client as they navigate their feelings and thoughts about their illness and impending death. Explanation: The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of grieving known as bargaining.

In the context of the five stages of grief proposed by Elisabeth Kübler-Ross, bargaining is the third stage. During this stage, individuals may attempt to negotiate or make deals with a higher power or the universe to change the outcome of their situation. They may express thoughts like "If only I could see this happen before I die," as a way to find some sense of control or hope amidst their terminal illness.

In this scenario, the client's desire to see their first grandchild born reflects the bargaining stage, where they are trying to find meaning and hope in their terminal condition by wishing for a specific event to occur before their passing.

The other stages of grief include:

A. Anger - In this stage, individuals may feel resentful, frustrated, or outraged about their situation or the circumstances leading to their illness.

B. Acceptance - The final stage in Kübler-Ross's model, acceptance, involves coming to terms with one's imminent death and finding peace and resolution.

D. Depression - In this stage, individuals may experience profound sadness and a sense of loss related to their impending death and the life they will leave behind.

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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.)

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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.)