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:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Correct Answer is A
Explanation
Choice A rationale:
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
Choice B rationale:
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
Choice C rationale:
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
Choice D rationale:
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
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