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 After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.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
Explanation
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.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,C"},"C":{"answers":"A"},"D":{"answers":"A,C"},"E":{"answers":"A,B,C"}}
Explanation
Rationale Assessment Findings Jaundice
Sickle Cell Disease: Yes. Jaundice occurs due to hemolysis of red blood cells, which is common in sickle cell disease as the sickled cells break down more rapidly than normal red blood cells.
Iron Deficiency Anemia: No. Jaundice is not a characteristic finding of iron deficiency anemia. Leukemia: No. Jaundice is not typically associated with leukemia.
Respiratory Status
Sickle Cell Disease: Yes. Clients may experience dyspnea and labored breathing due to vaso-occlusive crises, which can lead to lung involvement (acute chest syndrome).
Iron Deficiency Anemia: No. While severe anemia can lead to fatigue and shortness of breath, it does not typically cause labored breathing as a primary finding.
Leukemia: Yes. Respiratory issues can arise if leukemia causes significant bone marrow infiltration or if there is an infection due to immunosuppression.
Ankle Ulcer
Sickle Cell Disease: Yes. Chronic ulcers are common in sickle cell disease due to poor circulation and vaso-occlusive episodes.
Iron Deficiency Anemia: No. Ankle ulcers are not a characteristic finding in iron deficiency anemia. Leukemia: No. While leukemia can lead to skin issues or infections, ulcers are not a typical finding. Joint Pain
Sickle Cell Disease: Yes. Joint pain is a common symptom due to vaso-occlusive crises, where sickled cells block blood flow to the joints.
Iron Deficiency Anemia: No. Joint pain is not a common symptom of iron deficiency anemia.
Leukemia: Yes. Joint pain can occur due to leukemic infiltration of the bone marrow or as a side effect of treatments.
Heart Rate at 1000 (112/min)
Sickle Cell Disease: Yes. Tachycardia can occur in response to pain, hypoxia, or anemia due to sickle cell disease.
Iron Deficiency Anemia: Yes. Increased heart rate can occur as the body compensates for decreased hemoglobin and oxygen-carrying capacity.
Leukemia: Yes. Tachycardia can also be seen in leukemia, particularly if the patient is anemic or experiencing systemic effects of the disease.
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