The nurse is caring for a 12-year-old two days postoperative following open heart surgery. The child has refused to participate in physical therapy and ambulate. The nurse should initially
The nurse is caring for a 12-year-old two days postoperative following open heart surgery. The child has refused to participate in physical therapy and ambulate. The nurse should initially
A. have the parents reinforce the necessity for physical therapy.
[1%]
B. coordinate the client's physical therapy before meals.
[0%]
C. determine if the client is experiencing pain or discomfort.
[74%]
D. encourage the child to select the time that they want to ambulate.
[24%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Cardiovascular
Client Need
Test Plan
Management of Care
Related Topic
Establishing Priorities
Item Type
Item Type
Application
Explanation
Choice C is correct. Open heart surgery is a major operative procedure and may cause a client significant postoperative pain. It would be appropriate for the nurse to determine if the client is experiencing pain because untreated or undertreated pain may cause a client to retract from activities such as physical therapy and ambulation. These activities cause pain, and any procedure causing pain will likely have the child demonstrate reluctance.
Choice A is incorrect. Using the parents to reinforce the necessity for ambulation and participating in physical therapy could be helpful. Still, it also risks creating a conflict between the child and parents because, despite reinforcement, the child may get angry because of the pain. Treating the client's pain is a physical need and is the priority.
Choice B is incorrect. Coordinating the child's physical therapy based on their preference supports client autonomy. However, this intervention would be futile if the client is experiencing untreated pain.
Choice D is incorrect. Like the previous choice, client autonomy is key. However, coordinating the client's ambulation time while they are in pain is futile. The nurse needs to assess and treat pain that may be manifested by a client's lack of participation in activities that could cause discomfort.
Related Videos
4 Key Topics
Postoperative Care
11.5 Postoperative Management
Vital Signs
12.1 Clinical Assessment Overview
Additional Info
✓ The nurse should intervene if a client refuses to participate in ambulation or physical therapy. Most clients cite uncontrolled pain as a reason for their non-adherence.
✓ Nonverbal cues of a child in pain include acting out, withdrawing from activities, and facial changes such as grimacing.
✓ For a client scheduled for physical therapy or requiring ambulation, it would be prudent to premedicate the client with pain medication to enable optimal participation.
