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 B
Explanation
Choice A rationale
Positioning the infant supine increases pressure on the surgical site, potentially disrupting healing or increasing the risk of cerebrospinal fluid leakage. Supine positioning is contraindicated immediately after myelomeningocele repair as it can compromise the integrity of the repair.
Choice B rationale
Monitoring head circumference detects signs of hydrocephalus, a common complication after myelomeningocele repair due to cerebrospinal fluid dynamics. Enlarging head circumference can indicate increased intracranial pressure and require immediate intervention to prevent further neurological damage.
Choice C rationale
Intake and output monitoring provides essential hydration and renal function data post-surgery. While important, it is not the priority intervention immediately following surgery, as it does not directly address complications such as hydrocephalus or infection risk.
Choice D rationale
Maintaining skin integrity prevents infection and promotes healing but does not address potential neurological complications. While this intervention remains vital for recovery, it is secondary to detecting hydrocephalus or fluid imbalances post-surgery.
Correct Answer is C
Explanation
Choice A rationale
Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.
Choice B rationale
While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.
Choice C rationale
A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.
Choice D rationale
The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.
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