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 statement indicates that the client is actively trying to adapt to their condition by using adaptive equipment for feeding. Acknowledging spills but recognizing improvement reflects a positive attitude towards learning and gaining independence. This is a strong indication of adaptation.
B. While this statement shows that the client has the necessary equipment, preferring a bed bath suggests a reluctance to engage with the shower setup. It may indicate a lack of willingness to explore new methods for independence, which points to a slower adaptation process.
C. This statement suggests avoidance of social activities and a level of withdrawal from engaging with the outside world. This indicates a struggle with adjustment rather than successful adaptation to the home environment.
D. While enjoying life is important, relying on alcohol for pleasure may indicate unhealthy coping mechanisms. This statement does not demonstrate adaptation to the client's condition and may suggest avoidance of addressing the challenges of their new lifestyle.

A. Complete a neurological check on the client. B. Place the client in a rigid cervical collar. C. Open the client's airway using the jaw-thrust maneuver. D. Evaluate the client for other injuries.

Correct Answer is C

Explanation

A. While neurological assessments are important in understanding the extent of injury, they are not the immediate priority when a client is not breathing. The focus should be on ensuring airway patency and resuscitation.
B. Stabilizing the cervical spine is essential if there is a suspected fracture. However, if the client is not breathing, securing the airway is the most urgent need. Placing a collar can come after addressing the airway.
C. The jaw-thrust maneuver is specifically designed to open the airway without flexing the neck, which is crucial in suspected cervical spine injuries. Ensuring that the airway is open is the top priority for an unresponsive client who is not breathing.
D. While evaluating for other injuries is necessary in the context of a motor vehicle accident, this should occur after securing the airway. The primary concern is to address the life-threatening issue of the client not breathing.

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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 home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

Correct Answer is A

Explanation

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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