A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?

Maintain client on bed rest

Elevate the client's affected extremity.

Apply cold compresses to the client's affected extremity

Massage the muscle of the client's affected extremity

Answer and Explanation

The Correct Answer is B

A. Maintain client on bed rest: Strict bed rest is no longer routinely recommended for DVT unless complications arise. Early ambulation, if not contraindicated, can help prevent further clot formation and promote circulation. Prolonged immobilization may increase the risk of thrombus extension.

B. Elevate the client's affected extremity: Elevating the affected leg above heart level helps reduce venous pressure, swelling, and discomfort associated with DVT. This non-invasive intervention promotes venous return without increasing the risk of dislodging the thrombus, making it a safe and effective component of care.

C. Apply cold compresses to the client's affected extremity: Cold compresses are typically used for acute inflammation or localized trauma. In DVT, applying cold may not provide significant benefit and does not address the underlying venous obstruction or edema, so it is not routinely recommended.

D. Massage the muscle of the client's affected extremity: Massaging a limb with DVT is contraindicated because it can dislodge the thrombus, potentially causing a life-threatening pulmonary embolism. This action poses a high safety risk and must be strictly avoided.

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Correct Answer is D

Explanation

A. "Why do you think your life is not worth it anymore?": Asking “why” can feel judgmental and may cause the client to withdraw rather than share openly. It directs the conversation toward justification rather than safety assessment, delaying the nurse’s responsibility to determine immediate suicide risk.

B. "You can trust me and tell me what you are thinking": While supportive, this statement is too vague and does not address the urgent need to assess suicidal intent. It does not guide the client toward providing specific information needed to evaluate the level of risk and plan for safety.

C. "I need to know what you mean by misery": This response explores the client’s feelings but does not directly address the expressed suicidal thoughts. Focusing on the term “misery” may allow critical details about planning or intent to go unassessed during a potentially dangerous moment.

D. “Do you have a plan to end your life?”: This is an appropriate and essential safety-focused response because it directly assesses the client’s level of suicidal intent and the presence of a plan. Determining whether a plan exists helps the nurse evaluate the immediacy of the risk and initiate protective interventions without delay.

A. Plan the incorporation of new behaviors into daily life. B. Promote the client's dependence on the caregiver. C. Solve problems using a model applicable to the client's perspective. D. Mutually decide on the goals for the client's treatment

Correct Answer is D

Explanation

A. Plan the incorporation of new behaviors into daily life: This is part of the working phase of the therapeutic relationship, where interventions are implemented and the client practices new behaviors. It is not the focus of the orientation phase.

B. Promote the client's dependence on the caregiver: The goal of therapeutic relationships is to foster autonomy, trust, and self-efficacy, not dependence. Encouraging dependence can hinder the client’s progress and is not appropriate at any phase.

C. Solve problems using a model applicable to the client's perspective: Problem-solving occurs primarily during the working phase, once trust is established and goals are clear. It is not the main objective during the orientation phase.

D. Mutually decide on the goals for the client's treatment: The orientation phase focuses on building trust, establishing rapport, and collaboratively identifying goals for treatment. Engaging the client in goal setting ensures clarity, promotes cooperation, and sets the foundation for a therapeutic relationship.

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A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?

Nursing Test Bank

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