A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Provide the client with a fixed showerhead.

Give the client a long-handled sponge.

Fill the client's bathtub with water at 48° C (118.4° F).

Offer the client bar soap.

Answer and Explanation

The Correct Answer is B

A.   A fixed showerhead may not allow the client to effectively control the water flow or direction, which could limit their independence and ability to bathe safely. A handheld showerhead is generally more suitable as it enables the client to direct the water flow where needed.
B.   A long-handled sponge allows the client to reach different parts of their body without requiring significant movement, making bathing easier and more manageable. It promotes independence and safety, especially for clients with limited mobility.
C.   This temperature is too high and poses a risk of burns or scalding, especially for clients with spinal cord injuries who may have impaired sensation. The water temperature should be lower, typically around 37-40°C (98.6-104°F), to prevent injury.
D.   While bar soap can be used, it may not be the best option for individuals with limited hand function or dexterity. Liquid soap or body wash may be easier to handle and use, promoting independence and reducing frustration.

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Correct Answer is ["A","D","E"]

Explanation

A. Sexual activity can indeed trigger autonomic dysreflexia due to increased stimulation of the pelvic nerves, which can lead to a hypertensive crisis. This is particularly relevant for individuals with injuries at or above T6.
B. Loose clothing typically does not trigger autonomic dysreflexia. However, tight or constrictive clothing can be a potential irritant that may lead to dysreflexia. Thus, this option does not apply to the triggers of autonomic dysreflexia.
C. Nausea is not commonly identified as a trigger for this condition.
D. Surgery below the level of the injury can indeed trigger autonomic dysreflexia. This is because the body may perceive the surgical procedure as a noxious stimulus, leading to a reflexive autonomic response and an increase in blood pressure.
E. Urinary tract infections (UTIs) are a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The presence of infection can cause irritation and noxious stimulation of the bladder, leading to an autonomic response and hypertension.

A. Have the client floss 4 times daily. B. Administer an antiemetic prior to the procedure. C. Have the client swish with commercial mouthwash before therapy. D. Tell the client to expect dark stools following chemotherapy.

Correct Answer is B

Explanation

A. While maintaining oral hygiene is important, excessive flossing, especially in a client receiving chemotherapy, may increase the risk of gum bleeding due to potential thrombocytopenia (low platelet count). Instead, gentle oral care is recommended to prevent irritation and bleeding.
B. Chemotherapy can cause nausea and vomiting, and administering an antiemetic before treatment can help prevent these side effects. It is a standard practice to improve the client's comfort and adherence to treatment.
C. This action may not be advisable, particularly if the mouthwash contains alcohol or strong antiseptics, which can irritate mucous membranes, especially in clients undergoing chemotherapy. Instead, using a mild, alcohol-free mouthwash or a saline solution may be more appropriate for maintaining oral hygiene without causing irritation.
D. This statement is not typically accurate for all chemotherapy regimens. While some medications (like iron supplements) can cause dark stools, chemotherapy can lead to various gastrointestinal side effects, including diarrhea or constipation, rather than specifically dark stools.

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A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?(Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is B

Explanation

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