Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason: The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

Calculation steps:

Step 1: Determine the total volume to be infused. 1500 mL

Step 2: Determine the time for infusion. 2 hours

Step 3: Calculate the rate in mL/h. 1500 mL ÷ 2 hours Result: 750 mL/h

Choice A reason: A strong professional relationship does not involve personal plans outside of the therapeutic context.

Choice B reason: Countertransference refers to the nurse's emotional response to the client, not planning personal activities together.

Choice C reason: Successful relationship building occurs within professional boundaries and does not involve personal plans.

Choice D reason: The correct answer is d) because making personal plans with a client blurs the boundaries of the professional therapeutic relationship, which can affect the nurse's objectivity and professionalism.

Choice A reason: Systematic desensitization does not involve imitating the therapist's actions.

Choice B reason: Snapping a rubber band on the wrist is a different behavioral technique (aversion therapy), not systematic desensitization.

Choice C reason: Standing on a very high place until calm is not systematic desensitization, which involves gradual exposure.

Choice D reason: The correct answer is d) because systematic desensitization involves gradually increasing exposure to the feared stimulus (heights) to reduce the fear response.

Choice A reason: Clients on an involuntary hold may not have the right to refuse treatment if it is deemed necessary for their safety.

Choice B reason: The correct answer is b) because clients have the right to communicate with others, including mailing letters.

Choice C reason: The correct answer is c) because clients have the right to file grievances against staff if they feel their rights are being violated.

Choice D reason: A private room is not a guaranteed right for clients on an involuntary hold.

Choice E reason: The correct answer is e) because clients have the right to practice their religion and conduct religious practices.

Choice A reason: Referring the case to the ethics committee is not the immediate action required.

Choice B reason: The correct answer is b) because documenting the client's refusal ensures that it is noted in the medical record and appropriate follow-up actions can be taken.

Choice C reason: Administering the medication by another route without consent is not appropriate.

Choice D reason: Informing the client that she cannot refuse medication due to involuntary admission is not accurate; clients retain certain rights even when involuntarily admitted.

Choice A reason: The correct answer is a) because asking the client to write a sentence helps assess cognitive ability, including language and writing skills.

Choice B reason: Observing facial expression assesses mood, but it is not one of the three selected for understanding cognitive ability.

Choice C reason: Counting backward by sevens assesses cognitive function, but it is not selected in this question.

Choice D reason: The correct answer is d) because taking note of the client's nutritional status is part of assessing appearance.

Choice E reason: The correct answer is e) because asking the client to repeat a list of objects assesses recent memory.

Choice F reason: Asking the client to identify recent presidents assesses abstract thinking but is not one of the three selected for understanding the teaching.

Choice A reason: The correct answer is a) because the nurse is supporting the client's right to make an informed decision about their treatment.

Choice B reason: Beneficence involves doing good and acting in the best interest of the client, but the focus here is on supporting the client's decision-making.

Choice C reason: Fidelity refers to being faithful and keeping promises, which is not the primary focus in this scenario.

Choice D reason: Veracity refers to truthfulness, but the primary focus here is on supporting the client's autonomy.

Calculation steps:

Step 1: Identify the dosage required. 4 mg

Step 2: Identify the concentration available. 5 mg/mL

Step 3: Calculate the volume to be administered. 4 mg ÷ 5 mg/mL Result: 0.8 mL

Choice A reason: Explaining a legal obligation to share information is not accurate in this context.

Choice B reason: Advising the client that her supervisor will be informed is not necessary or appropriate.

Choice C reason: Telling the client her coworkers' opinions should not matter does not address the confidentiality concern.

Choice D reason: The correct answer is d) because informing the client that the information will be shared with the treatment team addresses the need for confidentiality while ensuring the team has the necessary information for treatment.