A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

"Everything will be okay."

"Why are you crying?"

"Do you think crying will help?"

“I will come back later and we can talk."

Answer and Explanation

The Correct Answer is D

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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Correct Answer is B

Explanation

A. Vitamin K is used to reverse the effects of warfarin, an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. It is not effective for reversing heparin. Therefore, this option is not appropriate in this context.
B. Protamine sulfate is the correct and specific antidote for heparin. It works by binding to heparin, neutralizing its anticoagulant effects. It is critical for managing situations where rapid reversal of heparin is needed, such as in cases of significant bleeding or prior to surgical procedures.
C. Deferasirox is an iron chelator used to treat chronic iron overload, typically in patients receiving repeated blood transfusions. It is not related to anticoagulation therapy and does not reverse the effects of heparin.
D. Acetylcysteine is primarily used as an antidote for acetaminophen (paracetamol) overdose and to
help with mucolysis in respiratory conditions. It does not have any role in reversing heparin’s effects.

A. Sexual intercourse B. Loose clothing C. Nausea D. Surgery below level of injury E. Urinary tract infections

Correct Answer is ["A","D","E"]

Explanation

A. Sexual activity can indeed trigger autonomic dysreflexia due to increased stimulation of the pelvic nerves, which can lead to a hypertensive crisis. This is particularly relevant for individuals with injuries at or above T6.
B. Loose clothing typically does not trigger autonomic dysreflexia. However, tight or constrictive clothing can be a potential irritant that may lead to dysreflexia. Thus, this option does not apply to the triggers of autonomic dysreflexia.
C. Nausea is not commonly identified as a trigger for this condition.
D. Surgery below the level of the injury can indeed trigger autonomic dysreflexia. This is because the body may perceive the surgical procedure as a noxious stimulus, leading to a reflexive autonomic response and an increase in blood pressure.
E. Urinary tract infections (UTIs) are a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The presence of infection can cause irritation and noxious stimulation of the bladder, leading to an autonomic response and hypertension.

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A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?(Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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