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 After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.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 ["A","B","C","D","E"]
Explanation
Choice A Reason:
Cancer is a significant risk factor for DIC, particularly certain types of leukemia and metastatic cancers. Cancer can trigger DIC through the release of procoagulant substances from tumor cells, leading to widespread clotting and subsequent bleeding. The hypercoagulable state associated with malignancies increases the risk of thrombotic events, which can precipitate DIC. Patients with advanced cancer are particularly susceptible due to the aggressive nature of the disease and the body's inflammatory response.
Choice B Reason:
Sepsis is one of the most common causes of DIC. Sepsis triggers a systemic inflammatory response that activates the coagulation cascade, leading to the formation of microthrombi throughout the vasculature. This widespread clotting depletes clotting factors and platelets, resulting in a paradoxical increase in bleeding risk. The severity of sepsis correlates with the likelihood of developing DIC, making early recognition and treatment of sepsis crucial.
Choice C Reason:
Trauma can lead to DIC through extensive tissue injury and the release of tissue factor into the bloodstream. Severe trauma, such as that from major accidents or surgeries, can overwhelm the body's hemostatic mechanisms, leading to uncontrolled clotting and bleeding. The inflammatory response to trauma further exacerbates the coagulation process, increasing the risk of DIC. Prompt management of traumatic injuries and monitoring for signs of DIC are essential in these patients.
Choice D Reason:
Pregnancy complications such as placental abruption, amniotic fluid embolism, and severe preeclampsia can precipitate DIC. These conditions cause significant endothelial damage and the release of procoagulant substances, triggering the coagulation cascade. The physiological changes during pregnancy, including increased blood volume and hypercoagulability, further predispose pregnant women to DIC. Early intervention and management of pregnancy-related complications are vital to prevent DIC.
Choice E Reason:
Blood transfusion reactions can lead to DIC through immune-mediated mechanisms. Incompatible blood transfusions can cause hemolysis and the release of procoagulant substances, initiating the coagulation cascade. The resulting widespread clotting and consumption of clotting factors can lead to bleeding complications. Careful matching of blood products and monitoring for transfusion reactions are critical to prevent DIC in transfusion recipients.
Correct Answer is A
Explanation
Choice A Reason:
Difficulty swallowing is a critical finding in a client with burns to the face, ears, and eyelids. This symptom can indicate airway edema or obstruction, which is a life-threatening condition. Burns in these areas can cause significant swelling, leading to compromised airways. Immediate intervention is required to secure the airway and prevent respiratory failure.
Choice B Reason:
Pain of 6 on a scale of 0 to 10 is important to manage for patient comfort and to prevent complications related to pain, such as increased heart rate and blood pressure. However, it is not the immediate priority over potential airway compromise. Pain management can be addressed once the airway is secured.
Choice C Reason:
A heart rate of 122/min indicates tachycardia, which can be a response to pain, stress, or hypovolemia. While it is important to monitor and manage, it is not as immediately life-threatening as airway obstruction. Tachycardia can be addressed after ensuring the airway is clear.
Choice D Reason:
Urinary output of 25 mL/hr is below the normal range (typically 30-50 mL/hr) and can indicate dehydration or renal impairment. While this is a concerning finding, it is not the immediate priority compared to securing the airway. Fluid resuscitation and renal function can be managed once the airway is stabilized.
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