A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Choice A reason: Financial power of attorney manages monetary decisions, not health care, unless specified as a health care surrogate. Advance directives guide health decisions, but this role is distinct, making this statement incorrect under the Patient Self-Determination Act’s provisions.
Choice B reason: The Patient Self-Determination Act ensures clients’ rights to refuse treatment, even against provider recommendations, promoting autonomy through advance directives. This legal protection applies in Medicare/Medicaid facilities, making it the correct principle for end-of-life decision-making in this context.
Choice C reason: Advance directives can be changed by a competent client, even if notarized, as the Act supports ongoing autonomy. Stating they cannot be altered is incorrect, as flexibility is a core feature, making this an inaccurate representation of the law.
Choice D reason: The eldest adult child cannot change advance directives unless designated as a surrogate. The Act prioritizes the client’s documented wishes or appointed decision-maker, not family hierarchy, making this statement incorrect and misaligned with legal requirements.

Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.