The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Correct Answer is ["B","C"]

Explanation

A. Suicide is a potential risk following sexual assault due to the emotional trauma that can ensue; however, it is not specific to males and therefore not the best answer in this context.
B. Depression is a common sequela of sexual assault among survivors due to the significant psychological impact of the trauma, which can lead to feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed.
C. Post-traumatic stress disorder (PTSD) is another frequent outcome of sexual assault, characterized by persistent mental and emotional stress as a result of injury or severe psychological shock. PTSD can manifest in nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event.
D. Becoming an abuser is a potential outcome for some survivors of sexual assault, but it is not one of the most common sequelae and is not supported by the literature as a primary risk for male survivors.
E. Human immunodeficiency virus (HIV) is a risk in cases of sexual assault where the transmission of bodily fluids occurs, but it is not a psychological sequela and thus not relevant to the question.
F. Chlamydia, like HIV, is a sexually transmitted infection that can be a risk in cases of sexual assault involving transmission of bodily fluids. However, it is not a psychological sequela and is not specific to the male gender in the context of sexual assault risk factors.

A. Numbness B. Poor decision making C. Crying D. Disbelief E. Irritability

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Numbness: Rape-trauma syndrome: Numbness can be a symptom of the acute phase of rape trauma syndrome, where individuals may experience emotional detachment or a sense of being emotionally overwhelmed.
- Poor decision making: Alcohol intoxication: Poor decision making is a common symptom of alcohol intoxication due to impaired judgment and cognitive function caused by alcohol consumption.
- Crying: occurs in both alcohol intoxication and rape-trauma syndrome. Crying is a common emotional response during the acute phase of rape-trauma syndrome as individuals may experience intense feelings of sadness, fear, or helplessness. Crying may also occur in individuals experiencing alcohol intoxication, especially if they become emotionally overwhelmed or as a result of disinhibition caused by alcohol consumption.

- Disbelief: Disbelief or denial is a typical reaction in the acute phase of rape-trauma syndrome as individuals may struggle to come to terms with the reality of the traumatic event.
- Irritability: Alcohol intoxication can lead to irritability because lowered inhibitions often trigger mood swings, aggression, or emotional lability, while in the acute phase of rape‑trauma syndrome survivors may also exhibit irritability as part of their emotional response, commonly expressed through anger, restlessness, or heightened anxiety; therefore, irritability is a behavior that can be observed in both conditions

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

Mark which behaviors might be related to alcohol intoxication, acute phase of rape- trauma syndrome, or both. Tick only 1 box.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

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