A nurse notices a teenage patient with paraplegia in a wheelchair crying. What should the nurse’s response be?

“I’ll return later, and we can talk.”.

“Everything will be okay.”.

“Do you feel like crying helps?”

“Would you like to be alone?”

Answer and Explanation

The Correct Answer is A

Choice A rationale

The nurse should respect the patient’s need for space while also expressing willingness to talk when the patient is ready.

Choice B rationale

Telling the patient “Everything will be okay” may seem dismissive of the patient’s feelings and may not be helpful in this situation.

Choice C rationale

Asking “Do you feel like crying helps?” might come across as judgmental or dismissive.

Choice D rationale

Asking “Would you like to be alone?” might make the patient feel isolated or abandoned.

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Correct Answer is A

Explanation

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

Correct Answer is ["1160"]

Explanation

Step 1: Convert All Fluid Intake to Milliliters (mL)

To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:

1 cup of coffee = 240 mL
4 oz of orange juice = 118.3 mL
3 oz of water = 88.7 mL
1 cup of flavored gelatin = 236.6 mL
1 cup of tea = 240 mL
5 oz of broth = 147.9 mL
3 oz of water (another serving) = 88.7 mL

Step 2: Calculate Total Fluid Intake

Add all the converted fluid amounts together:

Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL

Step 3: Round to the Nearest Whole Number

Round the total to the nearest whole number:

Rounded total = 1,160 mL

The nurse should record 1,160 mL on the patient’s chart.

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A nurse notices a teenage patient with paraplegia in a wheelchair crying. What should the nurse’s response be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the followingQuestions should the nurse include in the assessment?

Correct Answer is A

Explanation

Correct Answer is ["1160"]

Explanation

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