A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Allow the client to control the timing and frequency of the therapy.
Limit visiting hours until the client begins to participate in therapy
Establish a plan of care with the client that sets attainable goals.
Inform the client that privileges are related to participation in therapy.
The Correct Answer is C
Choice A Reason:
Allowing the client to control the timing and frequency of the therapy might seem beneficial, but it can lead to inconsistent participation and lack of progress. Structured therapy sessions are essential for rehabilitation, and while some flexibility is important, a completely client-controlled schedule may not provide the necessary consistency.
Choice B Reason:
Limiting visiting hours until the client begins to participate in therapy is not an effective approach. Social support from family and friends is crucial for the emotional well-being of the client and can actually motivate them to engage more in their rehabilitation efforts. Restricting visits could lead to increased feelings of isolation and resistance.
Choice C Reason:
Establishing a plan of care with the client that sets attainable goals is the most effective approach. Involving the client in their care plan fosters a sense of ownership and motivation. Setting realistic and achievable goals helps the client see progress, which can boost their confidence and willingness to participate in therapy.
Choice D Reason:
Informing the client that privileges are related to participation in therapy can be perceived as punitive and may not be effective in motivating the client. It is important to use positive reinforcement and encouragement rather than threats or restrictions to foster cooperation and engagement in the rehabilitation process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Improved blood flow to surrounding tissues is generally a desired outcome of treating an aneurysm, not a complication. When an aneurysm is successfully treated, the goal is to restore normal blood flow and prevent the aneurysm from rupturing. Improved blood flow indicates that the treatment was effective and that the risk of complications has been minimized.
Choice B Reason:
Rupture leading to severe internal bleeding is a significant potential complication of a treated aneurysm. Even after treatment, there is a risk that the aneurysm could rupture, especially if the treatment was not entirely successful or if the aneurysm was particularly large or complex. A rupture can lead to life-threatening internal bleeding and requires immediate medical attention. This is why ongoing monitoring and follow-up care are crucial for patients who have had an aneurysm treated.
Choice C Reason:
Decreased risk of blood clot formation is another desired outcome rather than a complication. Treating an aneurysm often involves measures to prevent blood clots, such as using anticoagulant medications. A successful treatment should reduce the risk of clot formation, which can otherwise lead to complications like stroke or embolism.
Choice D Reason:
Reduced risk of infection is also a desired outcome of aneurysm treatment. Infection can be a complication of any surgical procedure, including those used to treat aneurysms. However, with proper surgical techniques and post-operative care, the risk of infection can be minimized. Therefore, a reduced risk of infection is not a complication but rather an indication of successful treatment and good medical practice.
Correct Answer is A
Explanation
Choice A Reason:
Maintaining the cervical collar in place is crucial for a client with a spinal cord injury at the level of C3-4. This action prevents further damage to the spinal cord by immobilizing the neck and maintaining proper alignment. Any movement could exacerbate the injury, potentially leading to more severe neurological deficits or even paralysis.
Choice B Reason:
Asking the client if they remember any events around the time of the injury is not the priority in this situation. While obtaining a history is important, it should not take precedence over stabilizing the spinal cord to prevent further injury. The primary focus should be on ensuring the client's safety and preventing additional harm.
Choice C Reason:
Explaining to the client that they will never be able to walk again is inappropriate and premature. The prognosis for spinal cord injuries can vary widely, and it is essential to provide accurate information based on a thorough assessment and consultation with specialists. Additionally, delivering such news requires sensitivity and should be done in a supportive manner.
Choice D Reason:
Notifying the client's parents that they are in the ED is important for family communication and support. However, it is not the immediate priority. The primary focus should be on stabilizing the client's condition and preventing further injury. Once the client is stabilized, the nurse can then inform the family.
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