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 C
Explanation
Choice A rationale:
Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.
Choice B rationale:
White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.
Choice C rationale:
The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.
Choice D rationale:
Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.
Correct Answer is C
Explanation
A: Expecting heavier menstrual bleeding while using the patch is not a typical instruction given to clients. The patch may actually result in lighter, more regular bleeding.
B: The patch should not be placed on the upper thigh. According to the guidelines, the patch should be applied to clean, dry skin on the belly, buttocks, or back, and can also be placed on the outer part of the upper arm.
C: Applying the first patch within 24 hours of starting the menstrual cycle is correct. This ensures that the patch begins to work in sync with the client's natural cycle, providing immediate contraceptive protection.
D: A new patch should not be applied at the same time each day. Instead, it should be changed once a week on the same day, known as the "patch change day" to maintain consistent contraceptive coverage.
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