A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

"Everything will be okay."

"Why are you crying?"

"Do you think crying will help?"

“I will come back later and we can talk."

Answer and Explanation

The Correct Answer is D

A.   While this statement aims to offer reassurance, it may come off as dismissive of the client’s current feelings. The client is expressing deep emotions, and saying "everything will be okay" may minimize their experience. It’s better to acknowledge their feelings rather than trying to immediately reassure them without understanding the root of their distress.
B.   This response invites the client to express their feelings and thoughts but may come off as interrogative or insensitive, especially if the client is already upset. It might not provide the emotional support the client needs in that moment. A better approach would be to validate their emotions first.
C.   This response could be perceived as judgmental or sarcastic, potentially making the client feel invalidated or misunderstood. It does not offer the support they need and may discourage them from expressing their feelings further.
D.   This response shows empathy and respect for the client’s feelings. By acknowledging their need for space while also expressing a willingness to engage later, the nurse is providing a supportive approach. It allows the client to feel heard and valued without forcing them to communicate when they may not be ready.

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Correct Answer is D

Explanation

A. A white blood cell (WBC) count of 8,000/mm³ is within the normal range (typically 4,000- 11,000/mm³). This value does not indicate any immediate concern and does not need to be reported to the provider.
B. A PTT of 65 seconds is elevated, as the therapeutic range for PTT when on heparin is typically 1.5 to
2.5 times the normal range (usually around 25-35 seconds). An elevated PTT increases the risk of bleeding, and this should be reported to the provider for potential adjustment of heparin dosage or further evaluation.
C. A hematocrit of 45% is within the normal range for adult females (typically around 37-47%) and males (around 42-52%). This value does not indicate a concern that needs reporting to the provider.
D. A platelet count of 74,000/mm³ is low (thrombocytopenia), as the normal range is typically 150,000- 450,000/mm³. This finding is significant, especially in the context of heparin therapy, as low platelet counts can increase the risk of bleeding.

A. Manual wheelchair B. Sip-and-puff device C. Ultra-light wheelchairs D. Drive-adapted wheelchair

Correct Answer is B

Explanation

A. A manual wheelchair would not be appropriate for a client with a C4 spinal cord injury. At this level, the client typically has significant loss of motor function and limited ability to propel a manual wheelchair due to weakness in the upper extremities. Therefore, this option is not suitable.
B. A sip-and-puff device allows clients with limited mobility to control a powered wheelchair by inhaling or exhaling into a straw-like device. For a client with a C4 injury, this is a feasible mobility solution that enables independence without the need for significant upper body strength.
C. Ultra-light wheelchairs are designed for individuals who have the strength and ability to propel themselves or those who need minimal assistance. However, a client with a C4 spinal cord injury would likely lack the strength needed for an ultra-light wheelchair, making this option inappropriate.
D. A drive-adapted wheelchair can be customized for individuals with various disabilities, including those with limited mobility. However, while it can be suitable for higher-level injuries (like C4), it would depend on the client's overall condition and whether they have the ability to operate controls, often using adaptive technology.

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A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

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Correct Answer is B

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