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 After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.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 C
Explanation
Choice A Reason:
The irreversible stage of shock, also known as the terminal stage, is characterized by severe organ damage and failure. At this point, the body's compensatory mechanisms have failed, and recovery is unlikely. Decreased blood pressure and inadequate tissue perfusion are present, but they are more pronounced in the progressive stage.
Choice B Reason:
The refractory stage is often used interchangeably with the irreversible stage. It signifies a point where shock has progressed to such an extent that treatment is no longer effective. The body's organs have sustained irreversible damage, and despite medical intervention, the patient is unlikely to survive.
Choice C Reason:
The progressive stage of shock is characterized by a significant drop in blood pressure and inadequate tissue perfusion. During this stage, the body's compensatory mechanisms begin to fail, leading to worsening hypoperfusion and cellular damage. This stage is critical as it marks the transition from reversible to potentially irreversible damage if not promptly treated.
Choice D Reason:
The compensatory stage, also known as the non-progressive stage, involves the body's initial response to shock. During this stage, mechanisms such as increased heart rate and vasoconstriction work to maintain blood pressure and perfusion to vital organs. Blood pressure may still be within normal limits, and tissue perfusion is maintained, albeit at a reduced level.
Correct Answer is C
Explanation
Choice A: Administer intravenous pain medication
Administering intravenous pain medication is crucial for managing pain in burn patients. Pain management is essential to ensure the patient's comfort and to prevent complications such as shock. However, while important, it is not the immediate priority in this scenario. The primary concern should be assessing and securing the airway, especially given the location of the burns on the face and chest, which could indicate potential inhalation injuries.
Choice B: Draw blood for a complete blood cell (CBC) count
Drawing blood for a CBC count is important for assessing the patient's overall health and identifying any potential complications such as infection or anemia. However, this action is not the immediate priority. The nurse must first ensure that the patient's airway is clear and that there are no life-threatening conditions that need immediate attention.
Choice C: Inspect the mouth for signs of inhalation injuries
Inspecting the mouth for signs of inhalation injuries is the priority action. Burns to the face and chest can lead to inhalation injuries, which can cause airway obstruction and respiratory distress. Early identification and management of inhalation injuries are critical to prevent respiratory failure. Signs of inhalation injury may include soot around the mouth or nose, singed nasal hairs, and difficulty breathing. Ensuring the airway is clear and managing any inhalation injuries takes precedence over other actions.
Choice D: Insert an indwelling urinary catheter
Inserting an indwelling urinary catheter can be important for monitoring urine output, which is a key indicator of renal function and fluid balance in burn patients. However, this action is not the immediate priority. The nurse must first address any potential airway issues before proceeding with other interventions.
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