To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.

Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.