Psychosocial SATA

Question 30 See full question 1m 54s The nurse is caring for a mental health client who exhibits passive-aggressive behavior when interacting with the nursing staff. When reporting client behaviors to the next shift, which actions are consistent with this assessment? Select all that apply. You Selected: The client agrees with the staff but then complains to others. The client feels angry about the group session so he or she scatters papers in the lunchroom. Correct response: The client agrees with the staff but then complains to others. The client feels angry about the group session so he or she scatters papers in the lunchroom. Explanation: The client experiencing passive-aggressive behavior does not confront a situation directly but does something negative and potentially not even related to the situation in which they were upset. At times, the client may verbalize one thing and act in a different manner. A client who states that problems are not his or her fault may be refusing to accept responsibility for actions. Pouting reflects immature behavior. Attacking a nurse and then feeling remorse reflects aggressive behavior.

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Question 1 See full question 3m 39s The nurse is caring for a client whose cultural background is different than his or her own. Which nursing actions are appropriate? Select all that apply. You Selected: Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs through word and actions. Ask the client if there are cultural or religious requirements that should be considered in the plan of care. Correct response: Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs through word and actions. Ask the client if there are cultural or religious requirements that should be considered in the plan of care. Explanation: Nonverbal cues may have different meanings in different cultures. In one culture, eye contact may be a sign of disrespect; in another, eye contact may show respect and attentiveness. The nurse would always respect the client's cultural beliefs and ask if there are cultural or religious requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse would attempt to understand the client's culture; it is not the client's responsibility to understand the nurse's culture. The nurse would never impose his or her own beliefs/perspectives on clients. Culture influences a client's expression of pain. For example, pain may be openly expressed in one culture and quietly endured in another. Nursing interventions are client specific, which includes their cultural beliefs. Add a Note Question 2 See full question 6m 28s The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply. You Selected: Assist the client with activities of daily living (ADLs) as necessary. Furnish the client's environment with familiar possessions. Assign tasks in simple steps. Correct response: Furnish the client's environment with familiar possessions. Assist the client with activities of daily living (ADLs) as necessary. Assign tasks in simple steps. Explanation: A client with Alzheimer's disease experiences progressive deterioration in cognitive functioning. Familiar possessions may help to orient the client. The client should be encouraged to perform ADLs as much as possible but may need assistance with certain activities. Using a step-by-step approach helps the client complete tasks independently. A client with Alzheimer's disease functions best with consistent routines. Complex discussions do not improve the memory of a client with Alzheimer's disease. Add a Note Question 3 See full question 2m 23s The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply. You Selected: Abuse and neglect Unhealthy personal boundaries Correct response: Unhealthy personal boundaries Abuse and neglect Explanation: Healthy boundaries setting limits are established in childhood when parents provide consistent, supportive limits, and attention. In a dysfunctional family, the parents are unable to give the support, attention, care, discipline, and direction that children need in order to develop into mature adults. Often they are abused, emotionally or otherwise, or neglected. This leads to a poor self-concept and role confusion, the basis for unhealthy personal boundaries. Add a Note Question 4 See full question 5m 24s The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply. You Selected: Encourage ambulation Suggest a shower or bath Offer the use of a yoga ball Correct response: Encourage ambulation Suggest a shower or bath Offer the use of a yoga ball Explanation: This client has asked for a nonmedicated labor and birth. As the client advocate, the nurse should offer nonmedicated interventions and options. Encouraging ambulation, suggesting shower or bath, or offering the use of a yoga ball are nonmedication interventions appropriate for this stage of labor. Offering an epidural or giving IV pain medication, does not support the client in their choice of care. Add a Note Question 5 See full question 5m 55s A child is admitted to the child psychiatric unit for an Attention Deficit Hyperactivity Disorder (ADHD) assessment. What symptoms nurse would expect find? Select all that apply. You Selected: excessive fidgeting cannot wait to take turns easily distracted excessive climbing and running Correct response: excessive climbing and running excessive fidgeting cannot wait to take turns easily distracted Explanation: A child with ADHD will manifest excessive climbing and running, excessive fidgeting, inability to take turns, and distractibility. This child does not exhibit pouting or moody behaviors. Add a Note Question 6 See full question 9m 38s The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my wife? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply. You Selected: "Encourage your wife to rest in between contractions." "Stay by your wife's side. It is important that she know you are there to support her." "Continue to praise your wife and give her encouragement." Correct response: "Encourage your wife to rest in between contractions." "Continue to praise your wife and give her encouragement." "Stay by your wife's side. It is important that she know you are there to support her." Explanation: Transition is the time during labor where the client is 8-10 cm dilated. This is too early for the client to push and it is not uncommon for the client to be very irritable. Encouragement to sleep during contractions with praise and encouragement are appropriate interventions. During this period, the client is very anxious and may have a fear of being left alone. Keeping a presence at the client's bedside is an important intervention. Add a Note Question 7 See full question 2m 40s A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. You Selected: Answer the parents' questions accurately. Provide an early opportunity for the couple to see their child if they desire. Offer to stay with the grieving parents. Correct response: Provide an early opportunity for the couple to see their child if they desire. Offer to stay with the grieving parents. Answer the parents' questions accurately. Explanation: Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace. Add a Note Question 8 See full question 3m 10s A nurse is teaching a client stress management. Which of the following techniques would be considered adaptive coping skills? Select all that apply. You Selected: Balance sleep, rest, and exercise Set realistic goals for each day Practice relaxation techniques Correct response: Set realistic goals for each day Practice relaxation techniques Balance sleep, rest, and exercise Explanation: Stress affects everyone. So it is important for the nurse to assist the client to deal with the present stress and to build the ability to cope with future problems. Adaptive coping skills assist in this way and can assist the client in setting goals, practicing relaxation and balancing rest, sleep, and exercise. It is not possible to control one's life or totally eliminate anxiety. Things happen each day that are out of one's control, and anxiety results. The idea is to be able to deal with life as it comes. Add a Note Question 9 See full question 10m 43s A man brings his wife to the emergency department. He reports that since the death of their 7-month-old daughter 8 weeks earlier, his wife has been neglecting her housework and family, has lost 20 lb (9.1 kg), and has not left the house. Which of the following additional assessment findings would indicate to the nurse that the client may be experiencing extreme depression? Select all that apply. You Selected: Inconsolable weeping Speaking in soft monotone voice Obvious neglect of personal hygiene Correct response: Obvious neglect of personal hygiene Speaking in soft monotone voice Inconsolable weeping Explanation: Typically, a depressed client exhibits slow movements and fatigue and poor hygiene/grooming. Such a client also has difficulty interacting, speaking in a monotone voice, and avoiding eye contact. In extreme depression, the client may not communicate verbally at all, or the client may verbalize feelings of anger and lash out with irritability. Add a Note Question 10 See full question 8m 14s The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply. You Selected: "I can't drink even one or two beers." "If I am having trouble sleeping or eating, I will call the mental health center." Correct response: "If I am having trouble sleeping or eating, I will call the mental health center." "I can't drink even one or two beers." "Anxiety and worry causes me to have more voices." Explanation: In schizophrenia, the client and the family need to be given teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the physician's office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client's medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms. Add a Note Question 11 See full question 6m 37s A nurse is caring for an anorexic client with a nursing diagnosis of imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client? Select all that apply. You Selected: Monitor the client during meals and for 1 hour after meals. Monitor weight gain. Encourage the client to eat three substantial meals per day. Provide small, frequent meals. Correct response: Provide small, frequent meals. Monitor weight gain. Encourage the client to keep a journal. Monitor the client during meals and for 1 hour after meals. Explanation: Anorexia nervosa is an eating disorder characterized by excessive food restriction and irrational fear of gaining weight. Because the clients are engaged in self-starvation, clients with anorexia rarely can tolerate large meals three times per day. Small, frequent meals may be tolerated better and they provide a way to gradually increase daily caloric intake. The nurse would monitor the client's weight carefully because a client with anorexia may try to hide the weight loss. The nurse would also monitor the client during meals and for 1 hour afterward to ensure that the client consumes all of the food and does not attempt to purge. The client may be afraid to express feelings; keeping a journal can serve as an outlet for these feelings, which can assist recovery. A client with anorexia is already underweight and should not be permitted to skip meals. Add a Note Question 12 See full question 5m 40s An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply. You Selected: "Our child is just trying to get attention." "Our child would not do this again." "Our child will be fine in a couple of days." Correct response: "Our child is just trying to get attention." "Our child would not do this again." "Our child will be fine in a couple of days." Explanation: Suicide should not be seen just as attention-seeking behavior. It has very serious consequences and should never be minimized. To believe that such an attempt might not happen again or that the adolescent will have resolved the problems that led to the attempt in a couple of days shows a lack of understanding of the seriousness of the situation. Add a Note Question 13 See full question 2m 27s The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply. You Selected: reinforcing reality if the client is disoriented or hallucinating monitoring intake and output taking vital signs explaining to the client that the symptoms of withdrawal are temporary Correct response: taking vital signs monitoring intake and output reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary Explanation: For the client experiencing symptoms of alcohol withdrawal, the nurse monitors vital signs and intake and output, reinforces reality for the client who is confused, disoriented, or hallucinating, explains that the symptoms of withdrawal are temporary, reduces stimulation, and stays with the client if he is confused or agitated. The nurse administers medications to prevent the progression of symptoms, such as seizures and delirium tremens, and to ensure the client's safety. Restraints are not used as a precautionary measure. Restraints are used only as a least restrictive measure to protect the client and others when the client is a danger to himself or others. Add a Note Question 14 See full question 3m 44s The family of a client diagnosed with Alzheimer's disease wants to keep the client at home. They say that they have the most difficulty in managing his wandering. What should the nurse instruct the family to do? Select all that apply. You Selected: Install motion and sound detectors. Have the client wear a Medical Alert bracelet. Install door alarms and high door locks. Correct response: Install motion and sound detectors. Have the client wear a Medical Alert bracelet. Install door alarms and high door locks. Explanation: Motion and sound detectors, a Medical Alert bracelet, and door alarms and locks are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden. Add a Note Question 15 See full question 7m 33s The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. You Selected: Clients may not go to the bathroom for one-half hour to an hour after eating. Clients are not told their weight and cannot see their weight while being weighed. Clients are not allowed to discuss food or eating in groups or informal conversation with peers. Clients must eat within view of a staff member. Correct response: Clients must eat within view of a staff member. Clients are not told their weight and cannot see their weight while being weighed. Clients must rest within view of a staff member for one half hour to an hour after eating. Clients may not go to the bathroom for one-half hour to an hour after eating. Explanation: In hospital settings, clients are not allowed to know their weight at the time they are being weighed to decrease obsessing about weight gain. They must also eat and rest in staff view and cannot use the bathroom for a period to prevent discarding food or vomiting ingested food (purging). The rest prevents the client from exercising off the calories they just consumed. Barring clients from ever talking about food or attending groups until they have gained weight diminishes the therapeutic value of the inpatient hospital stay. Add a Note Question 16 See full question 4m 13s The nurse is caring for a client who developed fluctuating moods related to a recent cerebral vascular accident. When discussing the client's mood in a family meeting, which statements confirm a family's understanding of how to support the client? Select all that apply. You Selected: "I allow her to vent feelings and then find a different topic to discuss." "I do not take what she says personally and try to address the issue of anger." "Sometimes I sit down and cry too then we pick ourselves up and move on." Correct response: "I do not take what she says personally and try to address the issue of anger." "I allow her to vent feelings and then find a different topic to discuss." "Sometimes I sit down and cry too then we pick ourselves up and move on." Explanation: Changes in the brain that occur following the cerebral vascular accident can lead to periods of an emotional outburst resulting in anger or depression. The family may experience changes in their loved one that include uncharacteristic verbal outbursts or crying (pseudobulbar affect) within usual conversation. It is important to identify that these outbursts are a result of the illness and not take the outburst personally. Allowing the client to vent her feelings and experience the frustration with the client allows for the sharing of emotions and provides emotional support. Afterwards, moving on to a different topic or moving on within the day's activity does not allow the client to remain in the emotional state. Leaving the client or yelling at the client is not therapeutic to support the client through this time. Add a Note Question 17 See full question 7m 59s To establish a therapeutic relationship with an adolescent, which strategies are most likely to detract from the interview with the adolescent? Select all that apply. You Selected: asking personal questions unrelated to the situation writing down everything the teenager says discussing the nurse's own thoughts and feelings about the situation Correct response: asking personal questions unrelated to the situation writing down everything the teenager says discussing the nurse's own thoughts and feelings about the situation Explanation: Open-ended questions allow the adolescent to share information and feelings. The use of listening can be therapeutic and instills a sense of interest in the client. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he or she is being interrogated with unnecessary questions. Writing everything down during the interview can be a distraction and does not allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client. Add a Note Question 18 See full question 7m 32s A 3-year-old is seen in the well child clinic. The mother is concerned that the child may be autistic. Which of the following assessment data would indicate a concern to the nurse? Select all that apply. You Selected: Withdrawing into a private world Inability to develop social skills Lack of communication abilities Correct response: Lack of communication abilities Withdrawing into a private world Inability to develop social skills Explanation: Children with autism spectrum disorder (ASD) fail to develop interpersonal skills. The child with ASD withdraws into a private world and is not able to develop social skills and communication abilities. Inability to separate is a behavior found in children with separation anxiety. Inattention is associated with children who are diagnosed with Attention Deficit Disorder (ADD). Add a Note Question 19 See full question 1m 9s A nurse is caring for a spiritually distressed client. Which of the following are the factors affecting spiritual distress? Select all that apply. You Selected: Sociocultural deprivation. Chronic illness. Self-alienation. Correct response: Self-alienation. Chronic illness. Sociocultural deprivation. Explanation: Factors affecting spiritual distress include self-alienation, loneliness, or social isolation; anxiety; sociocultural deprivation; thought of death of self or dying of others; pain; life changes; and chronic illness of self or others. Disconnectedness to self can be expressed through an inability to introspect or an inability to see a religious leader. Add a Note Question 20 See full question 15m 16s A 54-year-old client with generalized anxiety disorder is admitted to the facility. Which therapeutic modalities are typically used to treat this disorder? Select all that apply. You Selected: Biofeedback Relaxation techniques Buspirone therapy Correct response: Biofeedback Buspirone therapy Relaxation techniques Explanation: Therapy for generalized anxiety disorder includes biofeedback, buspirone therapy, and relaxation techniques. Fluphenazine is prescribed to treat schizophrenia. Electroconvulsive therapy is indicated in severe depression and some cases of schizophrenia. Add a Note Question 21 See full question 2m 26s The nurse is admitting a client to the emergency department with symptoms of posttraumatic stress disorder (PTSD) after being in an earthquake. Which findings should the nurse anticipate? Select all that apply. You Selected: Experiences sleep disturbances and nightmares Has fears and anxiety over various things Hyper vigilance and poor concentration Correct response: Hyper vigilance and poor concentration Experiences sleep disturbances and nightmares Has fears and anxiety over various things Explanation: Survivors of earthquakes and other events outside the range of usual human experience produces significant distress in many people. PTSD is called that disorder in those people with the following symptoms: re-experiencing the event,nightmares,anxiety,phobias and marked arousal. Someone with symptoms of physical limitations and disabilities could have any number of problems but not PTSD. A person with PTSD may have memory problems related to the trauma but not to important information as their name or address. This maybe seen in someone with a dissociative disorder. Add a Note Question 22 See full question 3m 3s An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and x-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." What should the nurse tell the grandson? Select all that apply. You Selected: "The health care provider will look at the results of those tests in the ED and decide what other tests are needed." "Delirium commonly results from underlying medical causes that we need to identify and correct." "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." Correct response: "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." "The health care provider will look at the results of those tests in the ED and decide what other tests are needed." "Delirium commonly results from underlying medical causes that we need to identify and correct." Explanation: The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication prescriptions. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate. Add a Note Question 23 See full question 3m 3s Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply. You Selected: Focus on events and topics based in reality. Focus on the feelings or meaning of the delusion. Accept the client while not arguing with the delusion. Correct response: Accept the client while not arguing with the delusion. Focus on the feelings or meaning of the delusion. Focus on events and topics based in reality. Explanation: For the client with grandiose delusions, the nurse should accept the client but not argue with the delusion to build trust and the client's self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client's needs. Focusing on events and topics based in reality distracts the client from the delusional thinking. Confronting the client's delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when based in reality ignores the client's needs and therapeutic nursing intervention. Add a Note Question 24 See full question 1m 19s A parent brings their 10-year-old in to the pediatric clinic stating, "I think my child may be depressed. I have noticed several behavioral changes that were not present before the last few weeks." On assessment, which of the following behavioral changes may indicate depression? Select all that apply. You Selected: loss of appetite acting out in school stealing pens from another child's desk sleeping more often Correct response: loss of appetite acting out in school sleeping more often Explanation: Children exhibit depression differently than adults and may develop "acting out" behaviors such as anger, throwing things, and disciplinary issues that were not previously present. The child may have hypersomnia or sleep very little. Appetite can vary from poor intake to overeating. Stealing is not an indicator in childhood depression but may indicate other behavioral problems. The child with auditory hallucinations should be evaluated for childhood schizophrenia. Add a Note Question 25 See full question 1m 21s The father of a soldier who was killed 2 days ago is admitted after a serious suicide attempt. He is medically stable and has signed a no-harm contract. During a talk with the nurse, he says, "Terrorism and war are holding me and the whole world hostage. It is so unfair. I would rather be dead than live alone in constant fear." Which nursing interventions are important in the next few days? Select all that apply. You Selected: strategizing about ways to increase a personal sense of security identifying community groups for relatives of military personnel discussing effective ways to express justifiable anger Correct response: discussing effective ways to express justifiable anger teaching stress management and relaxation techniques identifying community groups for relatives of military personnel strategizing about ways to increase a personal sense of security Explanation: Dealing with anger, stress, and anxiety; identifying resources and support groups; and increasing a sense of safety and security are appropriate interventions at this time. However, recommending an antiwar advocacy group may or may not be appropriate, even much later in the client's recovery. Add a Note Question 26 See full question 4m 57s Which nursing action is appropriate when planning care for a client who is being battered? Select all that apply. You Selected: Give information about a safe home. Teach the client about the cycle of violence. Discuss the client's legal and personal rights. Provide a cell phone and the crisis help line telephone number. Correct response: Give information about a safe home. Provide a cell phone and the crisis help line telephone number. Teach the client about the cycle of violence. Discuss the client's legal and personal rights. Explanation: When working with a battered client, the nurse should give information about a safe home and provide a cell phone and information about the crisis help line. The nurse should also help the client understand the cycle of violence as well as personal and legal rights. The nurse should help the client share and discuss her anger, frustration, guilt, shame, and other feelings. Displacing, that is, placing feelings onto another person or object, is not helpful to the client and is not a healthy way to handle feelings. Add a Note Question 27 See full question 2m 9s A client has been rehospitalized with a severe exacerbation of lupus. Her husband approaches the nurse and says, "My wife is scaring me. She says she does not want to live with this illness anymore. Our kids are grown, and she feels useless as a mother and a wife." Which statements are the most appropriate responses to the husband? Select all that apply. You Selected: "We can talk about what you can say to her that may help." "I will have a talk with your wife to see if she is suicidal." "I am glad you shared this with me. I can imagine that this is scary for you." Correct response: "I will have a talk with your wife to see if she is suicidal." "I am glad you shared this with me. I can imagine that this is scary for you." "We can talk about what you can say to her that may help." Explanation: Suicide is a risk with chronic illnesses. The husband needs validation of his feelings and support, as well as suggestions for helping his wife with her concerns. Telling him to be strong and optimistic ignores the client's needs. It is false to assume that the client will no longer be suicidal when the lupus is under control. Add a Note Question 28 See full question 2m 54s A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which he lost both legs. The client states, "I will never be able to work again or live a normal life." Which responses by the nurse would be considered therapeutic? Select all that apply. You Selected: "Losing both legs is hard to accept, how are you feeling now?" "I am here to help you. Let's devise a plan so that you are working toward your goals." Correct response: "Losing both legs is hard to accept, how are you feeling now?" "I am here to help you. Let's devise a plan so that you are working toward your goals." Explanation: Having a life changing event frequently leaves individuals in a state of shock and overwhelmed with the situation. The client requires a supportive environment to meet his recovery needs. Validating his feelings and having the client express his feelings opens communication. Offering of self is another way to open communication and establish a trusting relationship. Setting mutually established client centered goals allows the client to feel involved and in control of the rehabilitation process. It is patronizing to state that the client will be up and walking soon. While that may be a true statement, the client has still experienced a significant loss. Asking about legal advice is not the role of the nurse. It is too early to determine job opportunities. The client will determine what opportunities interest him. Add a Note Question 29 See full question 1m 32s A 75-year-old woman was brought to the crisis center by her husband. The husband reports that his wife has been in shock and anxious since her purse was stolen outside of their home. The woman blames herself for being robbed, is worried about her stolen wallet and credit cards, and is afraid to go home. What nursing actions are indicated? Select all that apply. You Selected: Encourage her to talk about the robbery and her feelings. Discuss what changes at home would help her feel safe. Investigate if she has physical injuries from the robbery. Correct response: Encourage her to talk about the robbery and her feelings. Discuss what changes at home would help her feel safe. Investigate if she has physical injuries from the robbery. Explanation: After the impact of a crime, the client's most important needs are for physical safety and emotional security. There is no indication that the client has a severe level of anxiety; therefore, lorazepam is not indicated. Asking her how she could have prevented the robbery implies that she could be at fault. 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