A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

Inform the client that privileges are related to participation in therapy.

Limit visiting hours until the client begins to participate in therapy.

Allow the client to control the timing and frequency of the therapy.

Answer and Explanation

The Correct Answer is A

A.   This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.
B.   This option uses a form of coercion, implying that the client must comply with therapy to earn privileges. While consequences for non-participation can be a component of care, this approach may increase resistance and feelings of resentment.
C.   This approach is punitive and likely to worsen the client's emotional state. Limiting support from family and friends can increase feelings of isolation and abandonment, potentially leading to greater resistance to therapy.
D.   While offering the client some control can be beneficial, this option may lead to inconsistencies in therapy participation. If the client chooses to minimize their participation or avoid therapy altogether, it could hinder their rehabilitation progress. However, a balanced approach that includes some client choice alongside structured therapy may be beneficial.

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Correct Answer is B

Explanation

A. Vitamin K is used to reverse the effects of warfarin, an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. It is not effective for reversing heparin. Therefore, this option is not appropriate in this context.
B. Protamine sulfate is the correct and specific antidote for heparin. It works by binding to heparin, neutralizing its anticoagulant effects. It is critical for managing situations where rapid reversal of heparin is needed, such as in cases of significant bleeding or prior to surgical procedures.
C. Deferasirox is an iron chelator used to treat chronic iron overload, typically in patients receiving repeated blood transfusions. It is not related to anticoagulation therapy and does not reverse the effects of heparin.
D. Acetylcysteine is primarily used as an antidote for acetaminophen (paracetamol) overdose and to
help with mucolysis in respiratory conditions. It does not have any role in reversing heparin’s effects.

A. Independent control of bowel and bladder function B. Use of a wheelchair with a chin or mouth stick- C. Ability to achieve independent transfer from bed to wheelchair D. Ability to self-feed with the use of adaptive equipment

Correct Answer is B

Explanation

A. At the C5 level, the client is likely to have significant limitations in motor function and autonomic control below the level of the injury. While some bowel and bladder management can be achieved, full independence in these functions is generally not realistic at this level.
B. This goal is realistic for a client at the C5 level. Individuals at this level can often use a power wheelchair or manual wheelchair with adaptive devices such as a chin or mouth stick to propel themselves.
C. Achieving independent transfers from bed to wheelchair is typically not feasible for someone with a complete C5 spinal cord injury. At this level, significant upper body strength is necessary for transfers, which the client may not have.
D. With the use of adaptive equipment and assistive technologies, the client can achieve a level of independence in mobility and daily activities. However, it is not a primary goal.

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A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Correct Answer is B

Explanation

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