Patient Data.

Exhibits

What are three goals of therapy for this client? Select three that apply.

Choice A rationale:

Reporting the finding to the healthcare provider is important when the client no longer responds to commands and exhibits a specific response to pain. However, it should not be the first action. The nurse's initial response should be to assess and document the client's neurological status and response to pain to provide accurate information to the healthcare provider.

Choice B rationale:

Documenting the purposeful response to pain is the correct initial action in this scenario. The client's response, which involves pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward, is known as decerebrate posturing. It is a specific neurological response to painful stimuli and may indicate a brain injury. Documenting this response is crucial for the client's medical record and helps the healthcare provider assess the severity of the neurological injury.

Choice C rationale:

Initiating seizure precautions immediately is not the first action to take in this scenario. While the client's response to pain may resemble posturing seen in seizures, it is more indicative of a neurological injury or dysfunction. Further assessment and evaluation are needed before implementing seizure precautions.

Choice D rationale:

Administering a prescribed PRN analgesic is not the first action to take when the client exhibits decerebrate posturing in response to pain. This response indicates a neurological issue or injury that requires assessment and evaluation. Administering pain medication without a clear understanding of the underlying cause may not be appropriate and could potentially mask important neurological signs.

The correct answer is Choice B: Advise the client that lifestyle changes often take several weeks to be effective.

Choice B rationale: Exercise is known to improve sleep quality and reduce the time it takes to fall asleep; however, these benefits may not be immediate. Lifestyle modifications, such as incorporating regular physical activity, typically require several weeks before noticeable improvements in sleep patterns and overall health are observed. By informing the client about this expected timeframe, the nurse promotes realistic expectations and encourages adherence to the exercise program.

Choice A rationale: Encouraging daily exercise to eliminate bedtime wakefulness may be counterproductive, as overexertion can lead to increased arousal and impaired sleep quality. Additionally, daily exercise might be too rigorous or impractical for some individuals, potentially leading to burnout or injury. It is essential to tailor exercise recommendations to the client's fitness level, preferences, and goals.

Choice C rationale: While obtaining information about the client's exercise schedule is helpful in assessing their adherence and progress, it does not directly address the issue of sleep onset difficulties. The nurse should focus on providing education and guidance on the expected timeline for observing sleep improvements with exercise.

Choice D rationale: Weight loss is a potential outcome of increased physical activity but is not directly correlated with improvements in sleep onset latency. Focusing solely on weight loss may overlook other essential aspects of sleep hygiene and healthy lifestyle changes. The nurse should emphasize the broader benefits of exercise and provide a comprehensive approach to addressing the client's concerns.