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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Correct Answer is A
Explanation
Choice A rationale:
Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.
Choice B rationale:
Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.
Choice C rationale:
Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.
Choice D rationale:
Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.
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