A nurse in a pediatric rehabilitation unit is caring for a 15-year-old client who is recovering from a severe traumatic brain injury. The client's separated parents are arguing loudly at the bedside regarding the discharge plan. The mother insists on home care with a private aide, while the father demands placement in a residential facility. Both parents turn to the nurse and ask, "What do you think is the best choice for our child?" The client begins to cry, becomes restless, and the cardiac monitor shows a heart rate increase from 88 to 128 beats/min. Which action is the nurse's priority?
- State that the current conversation is distressing the client, ask the parents to move to the family lounge, and remain at the bedside to assess the client.Cevap
- BContact the unit social worker and case manager to arrange an urgent interdisciplinary family meeting to mediate the discharge conflict.
- CExplain to the parents that the rehabilitation team typically recommends the least restrictive environment to promote optimal cognitive recovery.
- DEncourage the parents to include the adolescent in their discussion to foster autonomy and developmentally appropriate decision-making.
Cevap
The priority action is to state that the conversation is distressing the client, direct the parents out of the room, and remain to assess the client.
The priority in any situation where a client's environment is causing acute distress is to protect the client and re-establish a therapeutic milieu. The client's sudden tachycardia and crying indicate a physiological and emotional stress response. By firmly but professionally asking the parents to move their conversation outside, the nurse removes the stressor, sets appropriate boundaries against triangulation, and allows for immediate assessment and comforting of the client.
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Anahtar Kavram
Family Dynamics, Triangulation, and Prioritization of Care