Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Exhibits grief response behaviors
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.
B. States a desire for revenge
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
C. Asks for advice about making life decisions
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.
D. Demonstrates an increase in regressive behavior
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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Full Explanation
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.
Similar Questions
A nurse is caring for a 19-year-old client who is dying following a motor vehicle crash. Which of the following individuals should the nurse approach first about considering organ donation?
A. The client's parent
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
B. The client's grandparent
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
C. The client's older sibling
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
D. The client's spouse
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Full Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
A. Apply lotion to the incisional site twice daily.
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
B. Avoid measuring blood pressure on the affected arm.
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
C. Apply deodorant under the affected arm daily.
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
D. Avoid lifting objects greater than 5.4 kg (12 lb).
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.
Full Explanation
Choice A rationale:
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
Choice B rationale:
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
Choice C rationale:
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
Choice D rationale:
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.
A nurse is teaching a female client who has obesity about a new prescription for phentermine/topiramate. Which of the following client statements indicates an understanding of the teaching?
A. "I might experience drowsiness while taking this medication."
Drowsiness is not a common side effect of phentermine/topiramate.
B. "This medication can cause an irregular menstrual cycle."
An irregular menstrual cycle is not a common side effect of phentermine/topiramate.
C. "I should not become pregnant while taking this medication."
Phentermine/topiramate is a medication used to assist with weight loss. Topiramate, one of the components of this medication, can increase the risk of birth defects if taken during pregnancy. Therefore, it is important for women of childbearing age to avoid becoming pregnant while on this medication and to use effective contraception.
D. This medication will cause me to have loose stools."
Loose stools are a potential side effect of phentermine/topiramate, but this statement does not necessarily indicate an understanding of the medication's purpose and precautions.
Full Explanation
Choice A rationale:
Drowsiness is not a common side effect of phentermine/topiramate.
Choice B rationale:
An irregular menstrual cycle is not a common side effect of phentermine/topiramate.
Choice C rationale:
Phentermine/topiramate is a medication used to assist with weight loss. Topiramate, one of the components of this medication, can increase the risk of birth defects if taken during pregnancy. Therefore, it is important for women of childbearing age to avoid becoming pregnant while on this medication and to use effective contraception.
Choice D rationale:
Loose stools are a potential side effect of phentermine/topiramate, but this statement does not necessarily indicate an understanding of the medication's purpose and precautions.