A nurse is assuming care of a client who has an existing deep-vein thrombosis (DVT). What interventions would be anticipated in their plan of care? (Select All that Apply).

Choice A rationale

While pharmacodynamics can vary among individuals, this response fails to educate the client on the primary mechanism of action of heparin, which is its role as an anticoagulant. Heparin works by potentiating the action of antithrombin III, an enzyme that inactivates clotting factors like thrombin, thus preventing the formation and growth of new clots.

Choice B rationale

This response is factually incorrect regarding heparin's primary function. Thrombolytic agents, such as alteplase (tPA), are designed to dissolve established clots by activating plasminogen to plasmin, which breaks down the fibrin mesh. Heparin is an anticoagulant and does not directly lyse (dissolve) existing thrombi; it merely stops their growth.

Choice C rationale

This response is also scientifically inaccurate regarding heparin's action. Heparin's main therapeutic benefit in thrombophlebitis is preventing clot extension and subsequent embolization (movement) of the clot to other locations, such as the lungs (pulmonary embolism), by interfering with the coagulation cascade, not by actively breaking down the pre-existing clot mass.

Choice D rationale

Heparin is an anticoagulant, which functions by inhibiting the synthesis or activity of one or more coagulation factors, primarily by augmenting antithrombin III, thus preventing the formation of new clots and halting the growth of existing ones. Fibrinolytic or thrombolytic drugs are the agents that actually dissolve an established thrombus; therefore, this response is scientifically accurate.

Choice A rationale

Stress incontinence is characterized by the involuntary loss of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting. This condition is typically caused by a weakened pelvic floor musculature or urethral sphincter incompetence, which is distinct from nerve damage following a spinal cord injury.

Choice B rationale

Overflow incontinence involves the involuntary leakage of urine from an overly full bladder that is unable to empty completely, leading to constant dribbling. This is often caused by an obstruction or an underactive detrusor muscle, resulting in large residual urine volumes, which is a potential but not the most specific result of spinal nerve damage.

Choice C rationale

Reflex incontinence is the involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached, without the client sensing the need to void. This is directly caused by a lack of communication and control between the brain and the bladder, a common consequence of upper motor neuron damage following a spinal cord injury.

Choice D rationale

Urge incontinence, or overactive bladder, is the involuntary loss of urine associated with a sudden, strong desire to void (urgency). It is typically caused by involuntary contractions of the detrusor muscle and is generally not the specific type of neurogenic bladder dysfunction directly and primarily associated with a debilitating spinal cord injury.