A nurse is evaluating the effectiveness of the plan of care for a client who has experienced sexual assault. Which of the following findings indicates effectiveness of the plan of care?

Exhibits grief response behaviors

States a desire for revenge

Asks for advice about making life decisions

Demonstrates an increase in regressive behavior

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.

Choice B rationale:

Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.

Choice C rationale:

A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.

Choice D rationale:

Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.

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Correct Answer is A

Explanation

Choice A rationale:

Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.

Choice B rationale:

Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.

Choice C rationale:

Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.

Choice D rationale:

A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.

A. Establish a therapeutic relationship with the client. B. Instruct the client on stress management techniques. C. Have the client sign a no-suicide contract. D. Maintain constant observation of the client.

Correct Answer is D

Explanation

Choice A rationale:

Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.

Choice B rationale:

Instructing the client on stress management techniques is important, but safety comes first.

Choice C rationale:

Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.

Choice D rationale:

Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.

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A nurse is evaluating the effectiveness of the plan of care for a client who has experienced sexual assault. Which of the following findings indicates effectiveness of the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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