A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?
Loosen the client's bed linens.
Provide bright lights in the client's room.
Massage the client's sacrum.
Offer to play music in the client's room.
The Correct Answer is D
A. Loosen the client's bed linens:
For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.
B. Provide bright lights in the client's room:
Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.
C. Massage the client's sacrum:
Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.
D. Offer to play music in the client's room:
Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The nurse's empathy about the client having to self-inject:
While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.
B. The client seeking family approval by agreeing to a teaching plan:
External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.
C. The nurse explaining the need for education to the client:
While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.
D. The client's belief that his needs will be met through education:
This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.
Correct Answer is C
Explanation
A. "You shouldn't worry about the future so you can concentrate on getting well.":
This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.
B. "If you work hard on your physical therapy, you won't need to worry.":
While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.
C. "You're concerned about what will happen when you leave the hospital?":
This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.
D. "Why are you concerned even though everyone is here to help you?":
This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.
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