A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Provide the client with a fixed showerhead.

Give the client a long-handled sponge.

Fill the client's bathtub with water at 48° C (118.4° F).

Offer the client bar soap.

Answer and Explanation

The Correct Answer is B

A.   A fixed showerhead may not allow the client to effectively control the water flow or direction, which could limit their independence and ability to bathe safely. A handheld showerhead is generally more suitable as it enables the client to direct the water flow where needed.
B.   A long-handled sponge allows the client to reach different parts of their body without requiring significant movement, making bathing easier and more manageable. It promotes independence and safety, especially for clients with limited mobility.
C.   This temperature is too high and poses a risk of burns or scalding, especially for clients with spinal cord injuries who may have impaired sensation. The water temperature should be lower, typically around 37-40°C (98.6-104°F), to prevent injury.
D.   While bar soap can be used, it may not be the best option for individuals with limited hand function or dexterity. Liquid soap or body wash may be easier to handle and use, promoting independence and reducing frustration.

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Correct Answer is B

Explanation

A. Neutropenic precautions are necessary for patients with low white blood cell counts (neutrophils), which increases the risk of infections. However, in this scenario, the child has a critically low platelet count, not necessarily low white blood cells.
B. This option refers to implementing bleeding precautions, which are critical for a child with low platelet counts (thrombocytopenia). This includes measures to prevent injury and bleeding, such as avoiding invasive procedures, using soft toothbrushes, and ensuring a safe environment.
C. Droplet precautions are used to prevent the spread of infections transmitted through respiratory droplets, such as influenza or COVID-19. While important for specific infections, this does not apply directly to the child's condition regarding leukemia and low platelets unless there is a concern for a respiratory illness.
D. Contact precautions are used to prevent the spread of infections through direct contact with the patient or their environment. This is important for infections that can be spread by touch. However, it is not the primary concern for a child with low platelet counts unless there is a known infectious risk.

A. "Everything will be okay." B. "Why are you crying?" C. "Do you think crying will help?" D. “I will come back later and we can talk."

Correct Answer is D

Explanation

A. While this statement aims to offer reassurance, it may come off as dismissive of the client’s current feelings. The client is expressing deep emotions, and saying "everything will be okay" may minimize their experience. It’s better to acknowledge their feelings rather than trying to immediately reassure them without understanding the root of their distress.
B. This response invites the client to express their feelings and thoughts but may come off as interrogative or insensitive, especially if the client is already upset. It might not provide the emotional support the client needs in that moment. A better approach would be to validate their emotions first.
C. This response could be perceived as judgmental or sarcastic, potentially making the client feel invalidated or misunderstood. It does not offer the support they need and may discourage them from expressing their feelings further.
D. This response shows empathy and respect for the client’s feelings. By acknowledging their need for space while also expressing a willingness to engage later, the nurse is providing a supportive approach. It allows the client to feel heard and valued without forcing them to communicate when they may not be ready.

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A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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