A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

Monitor for bleeding side effects related to heparin therapy.

Promote movement to prevent a pulmonary embolism.

Check blood pressure and heart rate at least every 4 hours.

Measure the circumference of each calf to assess for leg edema.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale

Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.

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Correct Answer is B

Explanation

Choice A rationale
Addiction refers to a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The intricate handwashing ritual that lasts two hours or more described by the client does not indicate substance use or dependency, which are common characteristics of addiction.
Choice B rationale

Compulsion refers to repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The client’s intricate handwashing ritual that lasts two hours or more and their concern about maintaining cleanliness align with the definition of a compulsion.
Choice C rationale
Obsession refers to recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and unwanted. While the client’s concern about maintaining cleanliness could potentially be seen as an obsession, the act of handwashing is a behavior, which aligns more with the definition of a compulsion.
Choice D rationale
Phobia refers to an extreme or irrational fear of or aversion to something. The client’s behavior does not indicate an extreme or irrational fear but rather a compulsion to maintain cleanliness through an intricate handwashing ritual.

A. Teach the client how to use guided imagery B. Instruct the client and family to reconsider end of life choices C. Record the client’s desire to live D. Encourage the family to bring the client old photographs E. Encourage the family to visit frequently .

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.

Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.

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A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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