A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
Limit fluid intake to prevent incontinence
Provide regular perineal care to prevent skin breakdown
Administer hypotonic IV fluids
Teach Kegel exercises to strengthen the pelvic floor
The Correct Answer is B
Choice A: Limit fluid intake to prevent incontinence. This is incorrect because limiting fluid intake can lead to dehydration, urinary tract infections, and kidney stones. Fluid intake should be adequate to maintain hydration and flush out bacteria from the urinary tract.
Choice B: Provide regular perineal care to prevent skin breakdown. This is correct because reflex incontinence can cause urine leakage and skin irritation, which can increase the risk of infection and pressure ulcers. Regular perineal care can help keep the skin clean and dry, and prevent complications.
Choice C: Administer hypotonic IV fluids. This is incorrect because hypotonic IV fluids can cause fluid overload, hyponatremia, and cerebral edema. Hypotonic IV fluids are not indicated for clients with reflex incontinence.
Choice D: Teach Kegel exercises to strengthen the pelvic floor. This is incorrect because Kegel exercises are effective for clients with stress or urge incontinence, but not for clients with reflex incontinence. Reflex incontinence is caused by a loss of voluntary control over the bladder due to a spinal cord injury, and Kegel exercises cannot restore this function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Epidemiology interprets legislation in the community is not a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is not directly involved in interpreting legislation, but rather in providing evidence and recommendations that can inform policy-making and law-making.
Choice B reason: Epidemiology relates to the health status of a population is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is the study of how diseases and other health-related factors are distributed and determined in populations. It helps the community health nurse to identify and monitor health problems, trends, and disparities in different groups and areas.
Choice C reason: Epidemiology analyzes and examines the root causes of health outcomes is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology uses various methods and tools to investigate and explain the causes and consequences of diseases and other health-related events. It helps the community health nurse to understand and address the complex and multifactorial factors that influence health, such as biological, environmental, social, behavioral, and economic factors.
Choice D reason: Epidemiology evaluates the effectiveness of nursing interventions is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology applies scientific principles and rigorous designs to assess and compare the outcomes and impacts of different interventions and programs on health. It helps the community health nurse to plan, implement, and evaluate evidence-based practices and policies that can improve health and quality of life.
Choice E reason: Epidemiology defines the burden of disease and determinants of health is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology measures and compares the frequency, severity, and impact of diseases and other health-related conditions on populations. It helps the community health nurse to prioritize and allocate resources, as well as to advocate for health equity and social justice.
Correct Answer is C
Explanation
Choice A reason: Administering an antipyretic is not the next action that the nurse should initiate. An antipyretic is a medication that lowers fever, which is a common symptom of meningococcal meningitis. However, fever is not a life-threatening condition, and it may have some beneficial effects on fighting infection. The nurse should first prioritize other actions that are more urgent or critical for the client's safety and outcome.
Choice B reason: Decreasing environmental stimuli is not the next action that the nurse should initiate. Decreasing environmental stimuli is a nursing intervention that can help reduce agitation, confusion, or seizures in clients with meningococcal meningitis. However, it is not an immediate or essential action, and it may not be effective if the client's condition worsens or progresses to coma.
Choice C reason: Assessing the cranial nerves is the next action that the nurse should initiate. Cranial nerve assessment is a neurological examination that evaluates the function of 12 pairs of nerves that originate from the brainstem and control various sensory and motor functions, such as vision, hearing, smell, taste, facial expression, eye movement, swallowing, speech, and balance. Meningococcal meningitis is an inflammation of the meninges, which are the membranes that cover and protect the brain and spinal cord. Meningeal inflammation can compress or damage the cranial nerves, causing various signs and symptoms, such as headache, photophobia, diplopia, facial palsy, dysphagia, dysarthria, or nystagmus. Assessing the cranial nerves can help detect any neurological deficits or complications early, and guide appropriate interventions or referrals.
Choice D reason: Completing a vascular assessment is not the next action that the nurse should initiate. A vascular assessment is a physical examination that evaluates the blood flow and circulation in different parts of the body, such as the arms, legs, abdomen, or neck. It may include checking pulses, blood pressure, capillary refill, skin color, temperature, or edema. A vascular assessment may be relevant for some clients with meningococcal meningitis who develop septic shock or disseminated intravascular coagulation (DIC), which are serious conditions that affect blood vessels and clotting factors. However, these are not common or early manifestations of meningococcal meningitis, and they require more advanced or specialized assessments and treatments.
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