A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
Limited fluid intake to prevent incontinence.
Administration of antispasmodic medication.
Kegel exercises to strengthen the pelvic floor.
Regular perineal care to prevent skin breakdown.
The Correct Answer is D
Choice A reason:
Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.
Choice B reason:
Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.
Choice C reason:
Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.
Choice D reason:
Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The epidemiologic triangle is a model used to explain the factors that contribute to the spread of infectious diseases. It consists of three components: the agent (the cause of the disease), the host (the organism harboring the disease), and the environment (the external factors that allow the disease to spread). This model helps nurses understand how diseases are transmitted and identify strategies for prevention and control.
Choice B reason:
Levels of prevention refer to the different stages of disease prevention: primary, secondary, and tertiary. While important for understanding how to prevent and manage diseases, this approach does not specifically explain the factors that allow the reproduction and spread of infectious diseases.
Choice C reason:
The natural history of disease describes the progression of a disease from its onset to its resolution, including the stages of preclinical, clinical, and recovery or death. While this concept is important for understanding disease progression, it does not focus on the factors that contribute to the spread of infectious diseases.
Choice D reason:
Health promotion involves activities and interventions designed to improve health and prevent disease. While health promotion is crucial for overall public health, it does not specifically address the factors that allow the reproduction and spread of infectious diseases.
Correct Answer is B
Explanation
Choice A reason:
The use of antibiotics to fight infections significantly improved health outcomes and reduced mortality rates from bacterial infections. However, antibiotics were not widely available until the mid-20th century. The dramatic increase in life expectancy began earlier, largely due to improvements in public health measures.
Choice B reason:
Sanitation and other public health activities were most responsible for the dramatic increase in life expectancy during the twentieth century. Improvements in sanitation, such as clean water supply, sewage treatment, and waste disposal, drastically reduced the incidence of infectious diseases. Public health initiatives, including vaccination programs and health education, also played a crucial role in preventing disease and promoting health.
Choice C reason:
Technology increases in the field of medical laboratory research have contributed to advancements in medical knowledge and treatment. While these technological advancements have improved diagnostic capabilities and treatment options, they were not the primary drivers of the initial increase in life expectancy during the early 20th century.
Choice D reason:
Advances in surgical techniques and procedures have significantly improved outcomes for many medical conditions. However, these advances primarily benefited individuals who had access to surgical care and did not have as widespread an impact on overall life expectancy as public health measures did.
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