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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A manual wheelchair would not be appropriate for a client with a C4 spinal cord injury. At this level, the client typically has significant loss of motor function and limited ability to propel a manual wheelchair due to weakness in the upper extremities. Therefore, this option is not suitable.
B. A sip-and-puff device allows clients with limited mobility to control a powered wheelchair by inhaling or exhaling into a straw-like device. For a client with a C4 injury, this is a feasible mobility solution that enables independence without the need for significant upper body strength.
C. Ultra-light wheelchairs are designed for individuals who have the strength and ability to propel themselves or those who need minimal assistance. However, a client with a C4 spinal cord injury would likely lack the strength needed for an ultra-light wheelchair, making this option inappropriate.
D. A drive-adapted wheelchair can be customized for individuals with various disabilities, including those with limited mobility. However, while it can be suitable for higher-level injuries (like C4), it would depend on the client's overall condition and whether they have the ability to operate controls, often using adaptive technology.
Correct Answer is A
Explanation
A. This value indicates leukopenia, which is a low white blood cell count. It is a common side effect of chemotherapy, as it can suppress bone marrow function and increase the risk of infection. A WBC count below 4000/mm³ is concerning and should be reported to the provider for potential intervention, such as monitoring for infection or adjusting chemotherapy.
B. A hemoglobin level of 12 g/dL is generally within the normal range for adult females (typically 12-16 g/dL). While chemotherapy can cause anemia, this specific level does not indicate a need for immediate reporting unless there are additional symptoms or changes.
C. An RBC count of 5 million/mm³ is also within the normal range for adult females (typically 4.2-5.4 million/mm³). This value does not warrant concern or reporting to the provider.
D. A platelet count of 155,000/mm³ is considered to be on the lower end of the normal range (typically 150,000-450,000/mm³). While it is not critically low, it may indicate the onset of thrombocytopenia, which can occur with chemotherapy. It should be monitored, but this specific value may not need immediate reporting unless there are additional clinical signs or significant drops in platelet counts.
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