The client has complained of stiffness and muscle tension in his ...

[colton]

The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. What action should the nurse take?
 
  1. Encourage the client to accept the back rub, saying how much it will relax the back muscles.
  2. Document that the client is noncompliant with the nursing plan of care.
  3. Accept the declination but tell the client to call if he changes his mind.
  4. Instruct the UAP to rub the client's back while assisting him to change into a clean gown.

Question 2

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem?
 
  1. Have the child walk around in the room when night terrors occur.
  2. The next morning, ask the child to describe the event.
  3. Have the child empty the bladder prior to going to bed.
  4. Use an additional pillow behind the child's head at night.

[bobsmith]

Answer to Question 1

Correct Answer: 3
Rationale 1: The nurse should not force the client to have a back rub if one is not desired.
Rationale 2: The client is not noncompliant; he is simply stating his preference.
Rationale 3: Some clients are eager to have a back rub, but others are not comfortable with the close physical contact this intervention requires. Respect the client's decision, but keep the offer open if he changes his mind.
Rationale 4: The UAP should not attempt to rub the client's back without permission.

Answer to Question 2

Correct Answer: 3
Rationale 1: Because this is a partial awakening, walking the child around the room will not help and the child will probably not awaken.
Rationale 2: The child will have no memory of the event the next morning.
Rationale 3: Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having the child empty the bladder before going to bed might be helpful.
Rationale 4: There is no reason to add an additional pillow behind the child's head.

[colton]

Thank you!

[bobsmith]

Always glad to help...