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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Reporting difficulty sleeping may be important but is not typically a critical concern in Guillain-Barre Syndrome.
Choice B Rationale: Removing the sequential compression device once a shift may require clarification or education but is not a significant medical concern.
Choice C Rationale: Hypoactive bowel sounds can indicate a potential bowel obstruction or paralytic ileus, which is a significant medical concern in clients with Guillain-Barre Syndrome and should be reported to the physician.
Choice D Rationale: A Glasgow Coma Score of 15 is within the normal range and would not typically require reporting to the physician in the context of Guillain-Barre Syndrome.
Correct Answer is ["A","C"]
Explanation
Choice A Rationale: Asking the spouse what she knows about dementia care options is a good starting point to assess her knowledge and provide information and resources, and empowering her to make informed decisions.
Choice B Rationale: Suggesting placement into a long-term care facility should not be the first option but can be explored if necessary, based on the client's condition and the caregiver's needs.
Choice C Rationale: Teaching the spouse about adult day care as a possible respite is a way of offering support and relief for the caregiver, who may experience stress and burnout from the constant demands of caring for a patient with AD.
Choice D Rationale: Suggesting that the spouse consult with the physician for antianxiety drugs is not helpful, as it may imply that the spouse's feelings are abnormal or that she needs medication to cope.
Choice E Rationale: Offering ideas for ways to distract or redirect the patient is not relevant to the spouse's needs, as it does not address her exhaustion and worry.
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