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 D
Explanation
Choice A Rationale: Leakage is not typically associated with upper motor neuron deficits related to a spinal cord injury.
Choice B Rationale: Anuria (absence of urine production) is not a common manifestation of upper motor neuron deficits in this context.
Choice C Rationale: A flaccid bladder and an inability to voluntarily void are more characteristic of lower motor neuron deficits. Upper motor neuron deficits often lead to spasticity and involuntary voiding.
Choice D Rationale: Spasticity and involuntary voiding are common manifestations of upper motor neuron deficits related to spinal cord injury. This is due to the loss of inhibitory control over reflexes, including the micturition reflex.
Correct Answer is A
Explanation
Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.
Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.
Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.
Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.
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