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 After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.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 D
Explanation
A. While respite care can be part of end-of-life care, it is not limited to terminally ill clients. Respite care is designed to provide temporary relief to caregivers for individuals with various chronic conditions, including disabilities like quadriplegia.
B. Respite care is not specifically related to psychological support after a death. Instead, it is intended to give caregivers a break from their caregiving responsibilities, regardless of the patient's prognosis. Thus, this response does not effectively describe the function of respite care.
C. While respite care can involve pain management and comfort measures, this statement does not fully capture the primary purpose of respite care, which is to provide temporary relief for caregivers. It may address some aspects of patient care, but it doesn't highlight the caregiver's need for a break.
D. Respite care is specifically designed to provide primary caregivers with relief from the daily responsibilities of caregiving. It allows them time to rest, attend to personal needs, or manage other responsibilities, which can help prevent caregiver burnout and improve overall well-being for both the caregiver and the client.
Correct Answer is B
Explanation
A. Neutropenic precautions are necessary for patients with low white blood cell counts (neutrophils), which increases the risk of infections. However, in this scenario, the child has a critically low platelet count, not necessarily low white blood cells.
B. This option refers to implementing bleeding precautions, which are critical for a child with low platelet counts (thrombocytopenia). This includes measures to prevent injury and bleeding, such as avoiding invasive procedures, using soft toothbrushes, and ensuring a safe environment.
C. Droplet precautions are used to prevent the spread of infections transmitted through respiratory droplets, such as influenza or COVID-19. While important for specific infections, this does not apply directly to the child's condition regarding leukemia and low platelets unless there is a concern for a respiratory illness.
D. Contact precautions are used to prevent the spread of infections through direct contact with the patient or their environment. This is important for infections that can be spread by touch. However, it is not the primary concern for a child with low platelet counts unless there is a known infectious risk.
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