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. 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.

A. The client has some movement and also some sensation below the level of the injury. B. The client has some movement but no sensation below the level of the injury. C. The client has some sensation but no movement below the level of the injury. D. The client has no sensation or movement below the level of the injury.

Correct Answer is D

Explanation

A. A complete spinal cord injury means that both sensory and motor functions are lost below the level of the injury. If the client had some movement and sensation, it would indicate an incomplete injury, which is not consistent with a complete transection.
B. This option describes a situation known as "motor incomplete," where there is preserved motor function but loss of sensory function below the level of injury. However, in a complete transection at C7, there would be no movement or sensation below that level, making this statement inaccurate.
C. This describes a condition where sensory pathways remain intact while motor pathways are disrupted, which is seen in incomplete spinal cord injuries. However, a complete transection at C7 would mean both movement and sensation are absent below the injury level, making this option incorrect.
D. In the case of a complete spinal cord transection at C7, the client would experience total loss of both sensation and movement below that level. This is consistent with the definition of a complete spinal cord injury.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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