A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS.

Calculate the rate at which the nurse should set the infusion pump.

d. Interview the client alone and assess for abuse

Explanation of Choices

Choice A Reason: Provide the Daughter and Client with Nutritional Counseling

While nutritional counseling is important, especially given the client’s malnourished state, it is not the immediate priority in this scenario. The client’s reluctance to speak and the daughter’s interruptions suggest that there may be underlying issues that need to be addressed first. Nutritional counseling can be provided later, once the immediate concerns have been resolved.

Choice B Reason: Request a Psychiatric Evaluation for the Client

Requesting a psychiatric evaluation may be necessary if there are signs of mental health issues, but it is not the first step in this situation. The priority is to ensure the client’s safety and well-being by addressing any immediate concerns, such as potential abuse. A psychiatric evaluation can be considered after the initial assessment and intervention.

Choice C Reason: Take the History from the Daughter Because of the Client’s Confusion

Taking the history from the daughter might seem practical due to the client’s confusion, but it is not the best approach in this case. The daughter’s constant interruptions and the client’s reluctance to speak raise concerns about the reliability of the information provided by the daughter. It is crucial to gather information directly from the client whenever possible to ensure an accurate assessment.

Choice D Reason: Interview the Client Alone and Assess for Abuse

Interviewing the client alone and assessing for abuse is the most appropriate intervention. The client’s reluctance to speak and the daughter’s interruptions could indicate that the client is being controlled or intimidated. Conducting a private interview allows the client to speak freely and provides an opportunity to identify any signs of abuse or neglect. Ensuring the client’s safety and addressing any immediate risks is the top priority.

a. You are safe now.

Explanation of Choices

Choice A Reason: You Are Safe Now

This statement is the most appropriate because it immediately addresses the client’s need for safety and reassurance. Victims of sexual assault often experience intense fear and anxiety. By reassuring the client that they are now in a safe environment, the nurse helps to stabilize the client’s emotional state and begins to build trust. This statement is crucial in creating a sense of security, which is the first step in providing effective care and support.

Choice B Reason: I’ll Call Your Spouse

While involving a support person can be beneficial, this statement does not address the client’s immediate emotional needs. The priority at this moment is to ensure the client feels safe and supported. Once the client is reassured and stabilized, the nurse can then discuss involving family members or other support persons. Immediate focus should be on the client’s safety and emotional well-being.

Choice C Reason: We’ll Have to Take Photographs of These Wounds

Taking photographs for forensic evidence is an important part of the medical and legal process following a sexual assault. However, this statement is not therapeutic and does not address the client’s immediate emotional needs. Discussing forensic procedures should come after the client feels safe and supported. The nurse should first focus on providing emotional reassurance before moving on to procedural details.

Choice D Reason: The Police Will Want to Interview You

Informing the client about the need for a police interview is necessary, but it is not the priority therapeutic statement at this moment. The client is likely already overwhelmed and distressed. The nurse should first provide reassurance and emotional support before discussing legal procedures. Ensuring the client feels safe and supported is essential before introducing additional stressors.