A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Allow the client to control the timing and frequency of the therapy.

Limit visiting hours until the client begins to participate in therapy

Establish a plan of care with the client that sets attainable goals.

Inform the client that privileges are related to participation in therapy.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Allowing the client to control the timing and frequency of the therapy might seem beneficial, but it can lead to inconsistent participation and lack of progress. Structured therapy sessions are essential for rehabilitation, and while some flexibility is important, a completely client-controlled schedule may not provide the necessary consistency.

Choice B Reason:
Limiting visiting hours until the client begins to participate in therapy is not an effective approach. Social support from family and friends is crucial for the emotional well-being of the client and can actually motivate them to engage more in their rehabilitation efforts. Restricting visits could lead to increased feelings of isolation and resistance.

Choice C Reason:
Establishing a plan of care with the client that sets attainable goals is the most effective approach. Involving the client in their care plan fosters a sense of ownership and motivation. Setting realistic and achievable goals helps the client see progress, which can boost their confidence and willingness to participate in therapy.

Choice D Reason:
Informing the client that privileges are related to participation in therapy can be perceived as punitive and may not be effective in motivating the client. It is important to use positive reinforcement and encouragement rather than threats or restrictions to foster cooperation and engagement in the rehabilitation process.

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Correct Answer is C

Explanation

Choice A: Vitamin K
Vitamin K is essential for the synthesis of clotting factors and is often used to treat bleeding disorders caused by vitamin K deficiency or to reverse the effects of anticoagulants like warfarin. However, in the context of disseminated intravascular coagulation (DIC), the primary issue is not a deficiency of clotting factors but rather an overactivation of the clotting cascade leading to both clot formation and bleeding. Therefore, while vitamin K can be beneficial in certain bleeding disorders, it is not the primary treatment for DIC.

Choice B: Statin
Statins are medications used to lower cholesterol levels and reduce the risk of cardiovascular disease. They work by inhibiting the enzyme HMG-CoA reductase, which plays a crucial role in cholesterol synthesis. Statins are not used in the management of DIC as they do not address the underlying pathophysiology of the condition, which involves widespread clotting and subsequent bleeding.

Choice C: Heparin
Heparin is an anticoagulant that helps prevent the formation of new clots and the extension of existing clots. In the management of DIC, heparin can be used to interrupt the clotting process and prevent further consumption of clotting factors. This can help stabilize the patient and reduce the risk of severe bleeding. Heparin is particularly useful in cases where thrombosis is predominant. It is important to monitor the patient closely to balance the risk of bleeding with the benefits of anticoagulation.

Choice D: Metformin
Metformin is an oral hypoglycemic agent used to manage type 2 diabetes by improving insulin sensitivity and reducing glucose production in the liver. It has no role in the treatment of DIC, as it does not affect the coagulation pathways or the underlying causes of DIC.

Correct Answer is ["20"]

Explanation

Step-by-Step Calculation:

Step 1: Identify the prescribed dose.

1000 units per hour

Step 2: Identify the concentration of heparin in the IV bag.

25,000 units in 500 mL

Step 3: Calculate the concentration of heparin per mL.

25,000 units ÷ 500 mL = 50 units/mL

Result = 50 units/mL

Step 4: Calculate the IV pump rate in mL/hr.

1000 units per hour ÷ 50 units/mL = 20 mL/hr

Result = 20 mL/hr

Final Result:

The IV pump should be set to 20 mL/hr.

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A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Susan, the nurse, is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?

Correct Answer is C

Explanation

Administer heparin 1000 units per hour IV. The pharmacy supplies the heparin infusion as 25,000 units in 500 mL D5W. What will the IV pump be set to? Please include the unit of measures.

Correct Answer is ["20"]

Explanation

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