An 18-year-old male has suffered a C5 spinal cord injury which has resulted in tetraplegia. His mother is crying in the waiting room 2 days after the injury has occurred. When the nurses sit down to talk to her, she asks whether her son will ever play football again. Which of the following responses would be best?
Reflect on how she's feeling, and encourage her to express other fears that she has about his injury.
Explain that you aren't sure, but you will ask the physician to talk to her right away.
Advise her that it isn't in his best interest for her to be so upset, and explain the importance of moral support
Reassure her that given time and motivation he will return to normal function.
The Correct Answer is A
A. Reflect on how she's feeling, and encourage her to express other fears that she has about his injury – Acknowledging emotions and encouraging open expression helps the mother process her grief and begin adjusting to the reality of the injury.
B. Explain that you aren't sure, but you will ask the physician to talk to her right away – Deferring to the physician misses an opportunity for emotional support.
C. Advise her that it isn’t in his best interest for her to be so upset, and explain the importance of moral support – This dismisses her emotions rather than addressing them.
D. Reassure her that given time and motivation he will return to normal function – Providing false reassurance is inappropriate, as a C5 spinal cord injury results in permanent loss of function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.
B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.
C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.
D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).
Correct Answer is A
Explanation
A. Obtain the patient's blood glucose level between 2a.m-4a.m – Correct Answer. The Somogyi effect occurs when nighttime hypoglycemia triggers a rebound hyperglycemia in the morning. Checking the blood glucose level during the early morning hours helps confirm this phenomenon.
B. Check the patient for a change in level of consciousness between 2a.m-4a.m – Incorrect. While severe hypoglycemia can affect consciousness, the best way to confirm the Somogyi effect is through blood glucose monitoring.
C. Withhold the nighttime snack and check the glucose at 6:00 a.m. – Incorrect. A nighttime snack can help prevent the hypoglycemia that leads to the Somogyi effect.
D. Administer an increased dose of NPH insulin in the evening. – Incorrect. Increasing insulin could worsen nighttime hypoglycemia, making the Somogyi effect worse.
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