A nurse is working on developing a safety plan with a client who ...

[ETearle]

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which of the following would the nurse address first?
 
  A) Devising an escape route
  B) Recognizing the signs of danger
  C) Identifying a safe place to hide
  D) Identifying a signal to indicate it is safe to leave

Question 2

While caring for a client age 88 years suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion?
 
  A) I am the king of the universe.
  B) Creatures are living in my closet.
  C) The government has people following me.
  D) My roommate keeps stealing my clothes.

[katheyjon]

Answer to Question 1

Ans: B
One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.

Answer to Question 2

Ans: D
Common delusional or suspicious thoughts for clients with dementia include People are stealing my things, This is not my house, and My relative is an imposter.