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 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.

A. "I need to make sure other members of my family get immunized against the disease." B. "Since I will stay in the hospital, I should begin the process of selling my home." C. "I will need to begin hospice care immediately." D. "I would like to talk to someone about creating a living will."

Correct Answer is D

Explanation

Choice A rationale:

Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.

Choice B rationale:

Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.

Choice C rationale:

Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.

Choice D rationale:

Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment for an older adult client. The nurse should identify that which of the following findings is a manifestation of possible elder maltreatment?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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