A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days.

The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

Choice A rationale:

Reporting the finding to the healthcare provider is important when the client no longer responds to commands and exhibits a specific response to pain. However, it should not be the first action. The nurse's initial response should be to assess and document the client's neurological status and response to pain to provide accurate information to the healthcare provider.

Choice B rationale:

Documenting the purposeful response to pain is the correct initial action in this scenario. The client's response, which involves pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward, is known as decerebrate posturing. It is a specific neurological response to painful stimuli and may indicate a brain injury. Documenting this response is crucial for the client's medical record and helps the healthcare provider assess the severity of the neurological injury.

Choice C rationale:

Initiating seizure precautions immediately is not the first action to take in this scenario. While the client's response to pain may resemble posturing seen in seizures, it is more indicative of a neurological injury or dysfunction. Further assessment and evaluation are needed before implementing seizure precautions.

Choice D rationale:

Administering a prescribed PRN analgesic is not the first action to take when the client exhibits decerebrate posturing in response to pain. This response indicates a neurological issue or injury that requires assessment and evaluation. Administering pain medication without a clear understanding of the underlying cause may not be appropriate and could potentially mask important neurological signs.

Choice A rationale:

The nurse should consider the patient's physical abilities and limitations when planning recreational activities because this information is crucial for ensuring the safety and appropriateness of the activities. For example, a patient with limited mobility may benefit from activities that can be done in a seated position, while a patient with greater physical abilities may be able to engage in more active pursuits.

Choice B rationale:

The patient's cognitive abilities and limitations should also be taken into account when planning activities. Some patients may have cognitive impairments that require simpler, more straightforward activities, while others may be able to participate in more complex or intellectually stimulating options. This ensures that the activities are enjoyable and suitable for the individual's cognitive capacity.

Choice C rationale:

Considering the patient's interests and preferences is essential to make the recreational activities meaningful and enjoyable. It is important to involve patients in activities they find interesting and pleasurable, as this can have a positive impact on their emotional and psychological well-being during the rehabilitation process.

Choice E rationale:

The patient's cultural and religious background is an important consideration when planning activities. Some activities may be more or less acceptable to individuals from different cultural or religious backgrounds. It's essential to respect cultural and religious preferences to ensure that the activities do not cause discomfort or offense to the patients.

Choice D rationale:

The patient's age and gender are not the primary factors to consider when selecting appropriate activities for individuals in a rehabilitation and restorative care setting. Age and gender do not necessarily determine a person's interests, physical abilities, or cognitive limitations. Therefore, they are not as relevant as the other factors listed in this context.