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 B

Explanation

Choice A rationale:

A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.

Choice B rationale:

Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.

Choice C rationale:

Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.

Choice D rationale:

Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.

A. Administer the phenytoin infusion over 5 min. B. Flush with 0.9% sodium chloride after administration. C. Flush with 100 units/mL of heparin after administration. D. Administer the phenytoin in 100 mL of D5W

Correct Answer is B

Explanation

Choice A rationale:

Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.

Choice B rationale:

Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.

Choice C rationale:

Flushing with heparin is not standard practice for administering phenytoin.

Choice D rationale:

Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.

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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?

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