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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Natural history of disease is not an approach that explains the factors that allow the reproduction and spread of infectious disease. Natural history of disease is a concept that describes the progression and outcome of disease in the absence of any intervention. It includes stages such as susceptibility, exposure, incubation, prodrome, clinical, recovery, disability, or death.
Choice B reason: Health promotion is not an approach that explains the factors that allow the reproduction and spread of infectious diseases. Health promotion is a process that enables people to increase control over and improve their health. It involves strategies such as education, advocacy, policy, or community development.
Choice C reason: Levels of prevention is not an approach that explains the factors that allow the reproduction and spread of infectious disease. Levels of prevention is a framework that classifies different types of interventions based on their timing and purpose. It includes primary prevention (before disease occurs), secondary prevention (early detection and treatment), and tertiary prevention (reducing complications and disabilities).
Choice D reason: Epidemiologic triangle is an approach that explains the factors that allow the reproduction and spread of infectious disease. Epidemiologic triangle is a model that identifies three essential components of an infectious disease: agent (the microorganism that causes the disease), host (the person or animal that is infected), and environment (the physical, biological, or social factors that influence the transmission). The interaction and balance among these components determine the occurrence and spread of an infectious disease.
Correct Answer is D
Explanation
Choice A reason: Developing a survey on teen pregnancies is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be relevant or important for the whole population. A survey also requires time and resources to design, distribute, and analyze.
Choice B reason: Holding a focus group to discuss immunizations is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be representative of the community's health needs and concerns. A focus group also requires recruitment, facilitation, and interpretation of the participants' views.
Choice C reason: Interviewing the elderly at the senior center is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific group that may not reflect the diversity and characteristics of the whole population. An interview also requires consent, rapport, and recording of the responses.
Choice D reason: Performing a windshield survey is a priority intervention for a public health nurse who is assigned to a new community. This is a general method that allows the nurse to observe and assess various aspects of the environment that affect the health and well-being of the population. A windshield survey also requires minimal resources and can be done quickly and easily. A windshield survey is a method of assessing the health needs and resources of a community by driving or walking around and observing various aspects of the environment, such as housing, transportation, services, and safety. This is a priority intervention for a public health nurse who wants to get a comprehensive overview of the community and identify its strengths and weaknesses.
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