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?
"My wife tries to get me to go to the grocery store, but I don't like to go out much."
"I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."
"My greatest pleasure each day is having a few beers every day."
"I am using the modified feeding utensils at every meal. I still spill, but I'm
The Correct Answer is D
Choice A Rationale: Expressing a reluctance to go out and preferring to stay indoors is not necessarily indicative of effective adaptation.
Choice B Rationale: Preferring a bed bath may be a personal choice rather than a sign of adaptation.
Choice C Rationale: Consuming alcohol daily as a means of pleasure may not necessarily indicate effective adaptation and may raise concerns about potential dependence.
Choice D Rationale: Using modified feeding utensils at every meal and acknowledging improvement despite occasional spills indicates a positive attitude toward adaptation and learning to manage daily activities despite physical limitations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
Correct Answer is B
Explanation
Choice A Rationale: hyperextension is when the neck is bent backward beyond its normal range of motion. This can happen in a rear-end collision or a fall on the back of the head.
Choice B Rationale: A spinal cord injury occurs when there is damage to the spinal cord or the surrounding structures, such as the vertebrae, ligaments, or discs. The most common cause of spinal cord injury is trauma, which can result from direct impact, penetration, or excessive force on the spine. Diving into shallow water can cause compression of the spine, which means that the vertebrae are pushed together and squeeze the spinal cord. This can damage the nerve fibers and disrupt the communicationbetween the brain and the body. Compression injuries can affect any part of the spine, but are more common in the cervical and thoracic regions.
Choice C Rationale: flexion-rotation is when the neck is bent and twisted at the same time. This can happen in a sports injury or a violent assault.
Choice D Rationale: This is when the neck is bent forward beyond its normal range of motion. This can cause the posterior part of the vertebral column to compress and fracture, while the anterior part of the spinal cord is stretched and injured. This can happen in a head-on collision or a fall on the face. A flexion-rotation is when the neck is bent and twisted at the same time.
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