A nurse caring for a client with a new spinal cord injury notices that the indwelling urinary catheter has stopped flowing. What is the nurses best first action?

Notify the physician

Check the tubing

Remove the indwelling catheter

Replace the indwelling catheter

Answer and Explanation

The Correct Answer is B

Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.

Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.

Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.

Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.

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Correct Answer is D

Explanation

Choice A Rationale: Dementia is not characterized by a sudden onset of confusion. It is a gradual and progressive condition.

Choice B Rationale: Dementia can be triggered or worsened by factors like infections, but it is not primarily characterized by a high fever or dehydration.

Choice C Rationale: An altered level of consciousness is not typically associated with dementia but may occur in acute delirium.

Choice D Rationale: The nurse should explain to the family that dementia is a chronic condition that affects the brain and causes cognitive impairment, memory loss, andbehavioral changes. The nurse should also inform the family that dementia is not caused by a single factor, but by a combination of genetic, environmental, and lifestyle factors. The nurse should emphasize that dementia is not a normal part of aging, and that it has different stages and types.

A. We need to reposition you. B. This is caused by a continual inflammatory process. C. This is related to nerve damage in the spinal cord D. This will go away in 2 weeks

Correct Answer is C

Explanation

Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.

Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.

Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.

Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.

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A nurse caring for a client with a new spinal cord injury notices that the indwelling urinary catheter has stopped flowing. What is the nurses best first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

I client with a spinal cord injury reports hot, burning, tingling, pain that shoots down his extremities. When the client asks why this occurs, what is the nurse's best response?

Correct Answer is C

Explanation

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The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

A nurse caring for a client with a new spinal cord injury notices that the indwelling urinary catheter has stopped flowing. What is the nurses best first action?

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?