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. "Wait until your child begins school to engage them in social activities." B. "Interact with your child according to their developmental age." C. "Devote more of your child's time to learning than to playing." D. "Teach your child several steps of a task at one time."

Correct Answer is B

Explanation

Choice A rationale:

Waiting until school age to engage in social activities is not appropriate, as social interaction is important for a toddler's development.

Choice B rationale:

Interacting with the child according to their developmental age is important for fostering appropriate growth and development.

Choice C rationale:

Devoting more time to learning than playing may not be appropriate, as play is an essential component of early childhood development.

Choice D rationale:

Teaching several steps of a task at one time may be overwhelming for a toddler with a cognitive delay. Instructions should be simple and broken down into manageable steps.

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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

A nurse is teaching the guardians of a toddler who has a cognitive delay. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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