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 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.

A. Specialized chemotherapy mask B. Chemotherapy gown C. Face shield D. Pair of chemotherapy gloves

Correct Answer is D

Explanation

A. A specialized chemotherapy mask is not typically required for the administration of oral chemotherapy. Masks may be necessary during certain procedures (like administering intravenous chemotherapy) where there is a risk of splashing or aerosolization, but they are not standard for oral administration.
B. A chemotherapy gown is generally not required for administering oral chemotherapy. These gowns are used for intravenous chemotherapy administration where there is a risk of drug spillage. For oral medications, the risk of exposure is significantly lower, so gowns are not standard practice.
C. A face shield is not typically needed when administering oral chemotherapy. Face shields are used to protect against splashes during procedures involving injectable forms of chemotherapy or other hazardous drugs, but oral administration does not pose the same risk of exposure.
D. The use of chemotherapy gloves is essential when handling oral chemotherapy agents. Gloves protect the nurse from potential exposure to the medication, especially if the drug is crushed or if there is any risk of spillage.

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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 A

Explanation

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Correct Answer is D

Explanation

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