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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
A. "You need to understand that you have very little time left":
This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.
B. "I will contact your provider to discuss your options":
This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan
C. "Enjoy the time you have and do the things you want to do":
This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.
D. "Hospice care is the best thing for you at this time":
While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.
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