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 D
Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
Correct Answer is C
Explanation
Choice A rationale:
Urine in acute glomerulonephritis often appears tea-colored or smoky due to hematuria.
Choice B rationale:
Hypertension is common in acute glomerulonephritis.
Choice C rationale:
Fluid retention and subsequent weight gain are common due to decreased kidney function.
Choice D rationale:
Hyponatremia is not typically associated with acute glomerulonephritis.
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