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 D
Explanation
Choice A reason: Analgesics are medications that relieve pain by blocking pain signals or reducing inflammation. They include nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen. However, analgesics are not very effective in treating trigeminal neuralgia, as they do not address the underlying cause of the pain, which is the compression or irritation of the trigeminal nerve.
Choice B reason: Antihistamines are medications that block the effects of histamine, a chemical that causes allergic reactions such as itching, sneezing, and swelling. They include diphenhydramine, cetirizine, and loratadine. Antihistamines are not effective in treating trigeminal neuralgia, as they do not affect the trigeminal nerve or its function.
Choice C reason: Antibiotics are medications that kill or inhibit the growth of bacteria that cause infections. They include penicillin, amoxicillin, and ciprofloxacin. Antibiotics are not effective in treating trigeminal neuralgia, as they do not target the trigeminal nerve or its pathology.
Choice D reason: Anticonvulsants are medications that prevent or reduce the frequency and severity of seizures by stabilizing the electrical activity of the brain. They include carbamazepine, gabapentin, and phenytoin. Anticonvulsants are the most effective medications in treating trigeminal neuralgia, as they reduce the abnormal firing of the trigeminal nerve that causes the pain. Anticonvulsants are considered the first-line therapy for trigeminal neuralgia and can provide significant relief for most clients.
Correct Answer is B
Explanation
Choice A reason: Mitral valve disease is not a disorder that makes clients especially vulnerable to ozone effects, as it does not affect the respiratory system. Mitral valve disease is a condition that affects the mitral valve, which is the valve that separates the left atrium and the left ventricle of the heart. Mitral valve disease can cause the valve to become narrow (stenosis) or leaky (regurgitation), affecting the blood flow and oxygen delivery to the body. Mitral valve disease can cause symptoms such as shortness of breath, fatigue, chest pain, palpitations, and swelling of the legs.
Choice B reason: Asthma is a disorder that makes clients especially vulnerable to ozone effects, as it affects the respiratory system. Asthma is a chronic inflammatory condition that causes the airways to become narrow, swollen, and sensitive to triggers such as allergens, irritants, infections, or exercise. Asthma can cause symptoms such as wheezing, coughing, chest tightness, and difficulty breathing. Ozone is a gas that is formed when sunlight reacts with pollutants in the air. Ozone can irritate the lungs and worsen asthma symptoms by causing inflammation, bronchoconstriction, and mucus production. Ozone can also reduce lung function and increase the risk of respiratory infections.
Choice C reason: Nasal polyps are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Nasal polyps are benign growths that form in the lining of the nose or sinuses. Nasal polyps can cause symptoms such as nasal congestion, runny nose, postnasal drip, loss of smell or taste, headache, and snoring. Nasal polyps are usually associated with chronic inflammation or allergies, but their exact cause is unknown.
Choice D reason: Seasonal allergies are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Seasonal allergies are allergic reactions that occur during certain times of the year when pollen or mold spores are high in the air. Seasonal allergies can cause symptoms such as sneezing, itching, watery eyes, runny nose, and sore throat. Seasonal allergies are caused by an overreaction of the immune system to harmless substances in the environment.
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