A. This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.
B. This option uses a form of coercion, implying that the client must comply with therapy to earn privileges. While consequences for non-participation can be a component of care, this approach may increase resistance and feelings of resentment.
C. This approach is punitive and likely to worsen the client's emotional state. Limiting support from family and friends can increase feelings of isolation and abandonment, potentially leading to greater resistance to therapy.
D. While offering the client some control can be beneficial, this option may lead to inconsistencies in therapy participation. If the client chooses to minimize their participation or avoid therapy altogether, it could hinder their rehabilitation progress. However, a balanced approach that includes some client choice alongside structured therapy may be beneficial.

A. Sexual activity can indeed trigger autonomic dysreflexia due to increased stimulation of the pelvic nerves, which can lead to a hypertensive crisis. This is particularly relevant for individuals with injuries at or above T6.
B. Loose clothing typically does not trigger autonomic dysreflexia. However, tight or constrictive clothing can be a potential irritant that may lead to dysreflexia. Thus, this option does not apply to the triggers of autonomic dysreflexia.
C. Nausea is not commonly identified as a trigger for this condition.
D. Surgery below the level of the injury can indeed trigger autonomic dysreflexia. This is because the body may perceive the surgical procedure as a noxious stimulus, leading to a reflexive autonomic response and an increase in blood pressure.
E. Urinary tract infections (UTIs) are a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The presence of infection can cause irritation and noxious stimulation of the bladder, leading to an autonomic response and hypertension.

A. At the C5 level, the client is likely to have significant limitations in motor function and autonomic control below the level of the injury. While some bowel and bladder management can be achieved, full independence in these functions is generally not realistic at this level.
B. This goal is realistic for a client at the C5 level. Individuals at this level can often use a power wheelchair or manual wheelchair with adaptive devices such as a chin or mouth stick to propel themselves.
C. Achieving independent transfers from bed to wheelchair is typically not feasible for someone with a complete C5 spinal cord injury. At this level, significant upper body strength is necessary for transfers, which the client may not have.
D. With the use of adaptive equipment and assistive technologies, the client can achieve a level of independence in mobility and daily activities. However, it is not a primary goal.

A. While neurological assessments are important in understanding the extent of injury, they are not the immediate priority when a client is not breathing. The focus should be on ensuring airway patency and resuscitation.
B. Stabilizing the cervical spine is essential if there is a suspected fracture. However, if the client is not breathing, securing the airway is the most urgent need. Placing a collar can come after addressing the airway.
C. The jaw-thrust maneuver is specifically designed to open the airway without flexing the neck, which is crucial in suspected cervical spine injuries. Ensuring that the airway is open is the top priority for an unresponsive client who is not breathing.
D. While evaluating for other injuries is necessary in the context of a motor vehicle accident, this should occur after securing the airway. The primary concern is to address the life-threatening issue of the client not breathing.

A. A fixed showerhead may not allow the client to effectively control the water flow or direction, which could limit their independence and ability to bathe safely. A handheld showerhead is generally more suitable as it enables the client to direct the water flow where needed.
B. A long-handled sponge allows the client to reach different parts of their body without requiring significant movement, making bathing easier and more manageable. It promotes independence and safety, especially for clients with limited mobility.
C. This temperature is too high and poses a risk of burns or scalding, especially for clients with spinal cord injuries who may have impaired sensation. The water temperature should be lower, typically around 37-40°C (98.6-104°F), to prevent injury.
D. While bar soap can be used, it may not be the best option for individuals with limited hand function or dexterity. Liquid soap or body wash may be easier to handle and use, promoting independence and reducing frustration.

A. Neutropenic precautions are necessary for patients with low white blood cell counts (neutrophils), which increases the risk of infections. However, in this scenario, the child has a critically low platelet count, not necessarily low white blood cells.
B. This option refers to implementing bleeding precautions, which are critical for a child with low platelet counts (thrombocytopenia). This includes measures to prevent injury and bleeding, such as avoiding invasive procedures, using soft toothbrushes, and ensuring a safe environment.
C. Droplet precautions are used to prevent the spread of infections transmitted through respiratory droplets, such as influenza or COVID-19. While important for specific infections, this does not apply directly to the child's condition regarding leukemia and low platelets unless there is a concern for a respiratory illness.
D. Contact precautions are used to prevent the spread of infections through direct contact with the patient or their environment. This is important for infections that can be spread by touch. However, it is not the primary concern for a child with low platelet counts unless there is a known infectious risk.

A. This option involves the client in their own care and encourages collaboration, which can foster a sense of control and motivation. By setting attainable goals together, the nurse can help the client see progress and feel empowered, potentially improving their willingness to participate in therapy.
B. While it’s important for clients to understand the consequences of their actions, using privileges as a reward for participation can come off as coercive. This approach might increase resistance and resentment, rather than encouraging the client to engage.
C. This option is punitive and likely to exacerbate the client’s feelings of isolation and withdrawal. Limiting support from family and friends can lead to greater resistance and may worsen the client’s emotional state.
D. Providing some level of control can be beneficial; however, allowing complete control over therapy timing may result in inadequate participation. While offering some choice is important, it needs to be balanced with structured therapy sessions to ensure the client receives the necessary rehabilitation.

A. Vitamin K is used to reverse the effects of warfarin, an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. It is not effective for reversing heparin. Therefore, this option is not appropriate in this context.
B. Protamine sulfate is the correct and specific antidote for heparin. It works by binding to heparin, neutralizing its anticoagulant effects. It is critical for managing situations where rapid reversal of heparin is needed, such as in cases of significant bleeding or prior to surgical procedures.
C. Deferasirox is an iron chelator used to treat chronic iron overload, typically in patients receiving repeated blood transfusions. It is not related to anticoagulation therapy and does not reverse the effects of heparin.
D. Acetylcysteine is primarily used as an antidote for acetaminophen (paracetamol) overdose and to
help with mucolysis in respiratory conditions. It does not have any role in reversing heparin’s effects.

A. Using pillows or specialized heel protectors helps to alleviate pressure on the heels, reducing the risk of pressure ulcers in bony prominences. Keeping the heels off the bed surface is an effective way to prevent skin breakdown.
B. Moisture from sweat, urine, or other sources can contribute to skin breakdown and increase the risk of pressure ulcers. Keeping the skin dry is essential for maintaining skin integrity and preventing irritation or maceration.
C. While turning the client is important to relieve pressure, every 4 hours may not be frequent enough, especially for individuals at high risk for skin breakdown. The standard recommendation is to turn clients at least every 2 hours to reduce prolonged pressure on any specific area.
D. While using powder can help absorb moisture and keep skin dry, it is important to avoid overuse, as excessive powder can cause buildup and irritation. Additionally, talcum powder is not recommended due to potential respiratory issues. Instead, using barrier creams or moisture-wicking fabrics may be preferable.
E. Massaging over bony prominences, especially areas that are already red (erythematous), can increase tissue damage and worsen skin breakdown. Instead, it is better to avoid direct pressure on these areas and use protective measures to relieve pressure.

A. Methotrexate can cause myelosuppression, leading to low platelet counts (thrombocytopenia), which increases the risk of bleeding. Checking the platelet count will help assess whether the bleeding gums are related to low platelet levels and determine the need for further intervention.
B. An electric toothbrush can be gentler on the gums and may help reduce trauma to the oral mucosa, which can help minimize bleeding. However, while it is a good practice, it is not the immediate priority compared to checking the platelet count.
C. This action may be appropriate, especially if the bleeding persists or is severe. A dental evaluation is important to rule out any underlying dental issues that could be causing the bleeding gums. However, this should not be the first response without first assessing the cause of the bleeding, such as checking the platelet count.
D. While some degree of bleeding may occur due to thrombocytopenia associated with methotrexate, it
is not appropriate to dismiss the client’s symptoms as merely an expected effect. Bleeding gums can indicate a serious issue, and it’s important to take such complaints seriously and investigate the underlying cause.