A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

Inform the client that privileges are related to participation in therapy.

Limit visiting hours until the client begins to participate in therapy.

Allow the client to control the timing and frequency of the therapy.

Answer and Explanation

The Correct Answer is A

A.   This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.
B.   This option uses a form of coercion, implying that the client must comply with therapy to earn privileges. While consequences for non-participation can be a component of care, this approach may increase resistance and feelings of resentment.
C.   This approach is punitive and likely to worsen the client's emotional state. Limiting support from family and friends can increase feelings of isolation and abandonment, potentially leading to greater resistance to therapy.
D.   While offering the client some control can be beneficial, this option may lead to inconsistencies in therapy participation. If the client chooses to minimize their participation or avoid therapy altogether, it could hinder their rehabilitation progress. However, a balanced approach that includes some client choice alongside structured therapy may be beneficial.

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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.

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 rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving chemotherapy for breast cancer. Which of the following precautions should the nurse perform during administration of oral chemotherapy?

Correct Answer is D

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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