The nurse is in a maternal/child unit and is caring for a new parent.
The new parent expresses concern about their safety in the home.
The nurse provides the client with an intimate partner violence crisis center number.
Which of the following is a way the nurse can evaluate the client's response to the safety plan?
The client thanks the nurse for the information.
The client puts the number of the crisis center into their phone.
The client thinks their home will be safer now that there is a baby in the house.
The client explains they are not planning to leave their home.
The Correct Answer is B
Choice A rationale
Thanking the nurse for information does not provide an actionable or measurable response to the safety plan. It signifies acknowledgment but does not demonstrate engagement or utilization of the resources provided. Effective evaluation involves observable actions that reflect the client's commitment to safety measures, such as storing or sharing resources.
Choice B rationale
Storing the crisis center number in their phone indicates the client values the provided resource and anticipates using it if necessary. It shows a proactive step in engaging with the safety plan and retaining information for future use. This measurable action demonstrates their awareness of the importance of having immediate access to help during emergencies.
Choice C rationale
The belief that their home will become safer due to the presence of a baby reflects denial or false optimism. It fails to address the inherent risks of intimate partner violence, which often escalate during stressful situations. A rational evaluation involves recognizing danger and taking steps to access resources for safety.
Choice D rationale
Choosing not to leave their home indicates resistance or inability to engage with the safety plan effectively. It reflects a lack of readiness to act on safety measures, making this response inappropriate as a measure of evaluating the safety plan. Behavioral change is necessary to ensure the client's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Elevating the head reduces the risk of aspiration by preventing stomach contents, including gastric juices, from entering the lungs. This position is essential for infants with tracheoesophageal fistula due to the abnormal connection between the trachea and esophagus, which increases aspiration risk.
Choice B rationale
Facilitating food digestion is not the primary goal of this positioning. Gastric motility and digestion are unaffected by head elevation, making this rationale irrelevant to the question. Therefore, this is not the correct choice.
Choice C rationale
While head elevation can improve breathing by reducing diaphragm compression, the primary purpose in this context is to prevent aspiration. Lung expansion is a secondary benefit, but it is not the main reason for this position.
Choice D rationale
Reducing stomach pressure is not the key reason for elevating the head in this case. Although head elevation can minimize intra-abdominal pressure, this rationale does not address the critical concern of preventing aspiration in tracheoesophageal fistula. .
Correct Answer is A
Explanation
Choice A rationale
Weight gain is a common side effect of corticosteroids, which alter metabolism and promote fluid retention. This effect can be pronounced in patients with muscular dystrophy, as corticosteroids are used to slow disease progression but may lead to unwanted changes in body composition.
Choice B rationale
Mood changes are another potential side effect of corticosteroids. These medications can affect neurotransmitter regulation in the brain, resulting in mood swings, irritability, or even more serious psychiatric effects such as depression or anxiety.
Choice C rationale
Chronic fatigue is not a primary side effect of corticosteroids. While muscular dystrophy itself may cause fatigue due to muscle wasting and decreased activity, the corticosteroids typically do not directly contribute to this symptom.
Choice D rationale
Osteoporosis is a long-term side effect of corticosteroid use, as these medications can interfere with calcium absorption and bone metabolism. Prolonged use may weaken bones, increasing the risk of fractures, especially in growing adolescents.
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