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 A
Explanation
Choice A reason: Giving the patient extra time to perform activities is an appropriate action by the nurse. Bradykinesia is a symptom of Parkinson's disease that causes slow and reduced movement, making it difficult for the patient to initiate and complete tasks. The nurse should respect the patient's autonomy and dignity, and allow them to do as much as they can by themselves, without rushing or interfering.
Choice B reason: Teaching the client to walk more quickly when ambulating is not an appropriate action by the nurse. Bradykinesia can affect the patient's gait and balance, making them prone to falls and injuries. The nurse should not encourage the patient to walk faster than their ability, but rather provide them with assistive devices, such as a cane or walker, and ensure a safe environment.
Choice C reason: Placing the client on a low-protein, low-calorie diet is not an appropriate action by the nurse. Bradykinesia does not require any specific dietary modifications, unless the patient has other comorbidities, such as diabetes or hypertension. The nurse should ensure that the patient has adequate nutrition and hydration, and avoid foods that may interfere with their medication absorption, such as high-fiber or high-fat foods.
Choice D reason: Completing passive range-of-motion exercises daily is not an appropriate action by the nurse. Bradykinesia can cause muscle stiffness and rigidity, which can limit the patient's range of motion and flexibility. The nurse should encourage the patient to do active range-of-motion exercises, which involve moving their own joints to their full extent, rather than passive ones, which involve someone else moving their joints for them. Active exercises can help maintain muscle strength and joint mobility and prevent contractures and deformities.
Correct Answer is B
Explanation
Choice A reason: Fluconazole (Diflucan) is an antifungal medication that is used to treat infections caused by fungi, such as candidiasis, cryptococcosis, and histoplasmosis. It is not effective against anthrax, which is a bacterial infection caused by Bacillus anthracis.
Choice B reason: Ciprofloxacin (Cipro) is an antibiotic medication that belongs to the class of fluoroquinolones. It is used to treat various bacterial infections, including anthrax. It works by inhibiting the DNA synthesis of the bacteria and preventing them from multiplying. Ciprofloxacin is one of the recommended medications for post-exposure prophylaxis and treatment of anthrax, according to the Centers for Disease Control and Prevention (CDC).
Choice C reason: Varenicline (Chantix) is a medication that is used to help people quit smoking. It works by blocking the effects of nicotine on the brain and reducing the cravings and withdrawal symptoms. It has no role in the prevention or treatment of anthrax.
Choice D reason: Potassium iodide (KI) is a medication that is used to protect the thyroid gland from radioactive iodine in the event of a nuclear or radiological emergency. It works by saturating the thyroid with non-radioactive iodine and preventing it from absorbing radioactive iodine. It has no role in the prevention or treatment of anthrax.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today