A rehabilitation 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 After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.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?
Establish a plan of care with the client that sets attainable goals.
Inform the client that privileges are related to participation in therapy.
Limit visiting hours until the client begins to participate in therapy.
Allow the client to control the timing and frequency of the therapy.
The Correct Answer is A
A. This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.
B. This option uses a form of coercion, implying that the client must comply with therapy to earn privileges. While consequences for non-participation can be a component of care, this approach may increase resistance and feelings of resentment.
C. This approach is punitive and likely to worsen the client's emotional state. Limiting support from family and friends can increase feelings of isolation and abandonment, potentially leading to greater resistance to therapy.
D. While offering the client some control can be beneficial, this option may lead to inconsistencies in therapy participation. If the client chooses to minimize their participation or avoid therapy altogether, it could hinder their rehabilitation progress. However, a balanced approach that includes some client choice alongside structured therapy may be beneficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Sexual activity can indeed trigger autonomic dysreflexia due to increased stimulation of the pelvic nerves, which can lead to a hypertensive crisis. This is particularly relevant for individuals with injuries at or above T6.
B. Loose clothing typically does not trigger autonomic dysreflexia. However, tight or constrictive clothing can be a potential irritant that may lead to dysreflexia. Thus, this option does not apply to the triggers of autonomic dysreflexia.
C. Nausea is not commonly identified as a trigger for this condition.
D. Surgery below the level of the injury can indeed trigger autonomic dysreflexia. This is because the body may perceive the surgical procedure as a noxious stimulus, leading to a reflexive autonomic response and an increase in blood pressure.
E. Urinary tract infections (UTIs) are a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The presence of infection can cause irritation and noxious stimulation of the bladder, leading to an autonomic response and hypertension.
Correct Answer is A
Explanation
A. This option involves the client in their own care and encourages collaboration, which can foster a sense of control and motivation. By setting attainable goals together, the nurse can help the client see progress and feel empowered, potentially improving their willingness to participate in therapy.
B. While it’s important for clients to understand the consequences of their actions, using privileges as a reward for participation can come off as coercive. This approach might increase resistance and resentment, rather than encouraging the client to engage.
C. This option is punitive and likely to exacerbate the client’s feelings of isolation and withdrawal. Limiting support from family and friends can lead to greater resistance and may worsen the client’s emotional state.
D. Providing some level of control can be beneficial; however, allowing complete control over therapy timing may result in inadequate participation. While offering some choice is important, it needs to be balanced with structured therapy sessions to ensure the client receives the necessary rehabilitation.
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