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

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.

ANSWER

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.