A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

Rationale for correct choices

• heparin 30 units/kg IV bolus once: The diagnostic ultrasound confirms a thrombus in the right leg, indicating acute DVT. Anticoagulation with heparin is the first-line intervention to prevent clot extension and pulmonary embolism. The lab values (normal platelets, normal INR) show no contraindication to starting anticoagulation.

• acetaminophen 650 mg PO every 4 hr PRN: Acetaminophen is appropriate for managing the client’s pain (rated 6/10) without increasing bleeding risk. NSAIDs such as ibuprofen are avoided in DVT because they can impair platelet function and increase bleeding risk once anticoagulation is initiated.

Rationale for incorrect choices

• initiating fluid restriction: Fluid restriction is typically used in conditions like heart failure or hyponatremia, not DVT. Adequate hydration is beneficial in DVT because it helps maintain blood viscosity and supports circulation without affecting clot stability.

• maintaining the extremity below the level of the heart: Lowering the extremity increases venous pressure and can worsen swelling. For DVT, the extremity is usually elevated to promote venous return and reduce edema, so this option does not align with recommended care.

• administering cold packs to the extremity: Cold therapy can cause vasoconstriction and slow venous blood flow, which may worsen thrombosis. Warm compresses improve circulation but are used cautiously and only with provider guidance.

Rationale:

A. The client's frequency of incontinence has decreased: Incontinence is not a direct measure of blood glucose control or the effectiveness of metformin. Changes in urinary frequency may be influenced by other conditions, such as urinary tract infections or prostate issues, and do not indicate the medication’s success.

B. The client's iron level has increased: Metformin does not affect iron metabolism. An increase in iron levels would be unrelated to metformin therapy and could reflect dietary changes, supplementation, or other underlying conditions.

C. The client's high-density lipoprotein level has increased: While metformin may have mild beneficial effects on lipid profiles, its primary purpose is to improve glycemic control. Changes in HDL are not the main indicator of therapeutic success for this medication.

D. The client's HbA1c has decreased: HbA1c reflects average blood glucose levels over the past 2–3 months. A decrease indicates improved glycemic control, which is the primary goal of metformin therapy. Monitoring HbA1c is the most reliable measure to evaluate the effectiveness of the medication.