The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?

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.

Choice A Reason:
Pneumonia is an infection of the lungs, not the ear. It primarily affects the alveoli, causing symptoms like cough, fever, and difficulty breathing. While respiratory infections can sometimes lead to ear infections, pneumonia itself does not directly infect the ear.

Choice B Reason:
Endocarditis is an infection of the inner lining of the heart chambers and valves. It is typically caused by bacteria entering the bloodstream and does not affect the ear. Symptoms include fever, heart murmurs, and fatigue.

Choice C Reason:
Myocarditis is an inflammation of the heart muscle, usually caused by viral infections. It affects the heart's ability to pump blood and does not involve the ear. Symptoms can include chest pain, fatigue, and shortness of breath.