A nurse is caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal quadrants. Which of the following actions should the nurse perform?
Place the client on clear liquids.
Perform a hemoccult blood test.
Insert a nasogastric tube.
Force the intake of fluids.
The Correct Answer is C
Choice A Reason:
Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.
Choice B Reason:
Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.
Choice C Reason:
Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.
Choice D Reason:
Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A Reason:
Photosensitivity is incorrect. Photosensitivity, or sensitivity to light, is not a common symptom of multiple sclerosis. While individuals with MS may experience visual disturbances, such as blurred vision or optic neuritis, sensitivity to light is not typically reported as a primary symptom.
Choice B Reason:
Memory issues is correct. Memory issues, including problems with short-term memory, concentration, and cognitive processing speed, are common neurological symptoms in individuals with multiple sclerosis. Cognitive impairment can affect various aspects of memory and cognitive function.
Choice C Reason:
Lhermitte's sign is correct. Lhermitte's sign is a classic neurological sign characterized by an electric shock-like sensation that radiates down the spine or into the limbs upon flexing the neck. It is a common symptom in multiple sclerosis, often associated with cervical spinal cord lesions.
Choice D Reason:
Seizures is incorrect. Seizures are not a typical symptom of multiple sclerosis. While individuals with MS may experience various neurological symptoms, seizures are not a common manifestation of the disease.
Choice E Reason:
Central vision loss is correct. Visual disturbances, including central vision loss, blurred vision, double vision, or optic neuritis, are common symptoms of multiple sclerosis. Optic neuritis, inflammation of the optic nerve, is a frequent manifestation of MS that can lead to temporary or permanent central vision loss.
Correct Answer is ["B","C","D"]
Explanation
Choice A Reason:
Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood and is not typically associated with degenerative disc disease. This finding is unrelated to the pathophysiology of DDD.
Choice B Reason:
Paresthesia is correct. Yes, paresthesia, which refers to abnormal sensations such as tingling, numbness, or burning, can develop with degenerative disc disease. Nerve compression or irritation due to disc degeneration can lead to paresthesia in the affected area, typically radiating along the nerve pathway.
Choice B Reason:
Foot drop is correct. Yes, foot drop can develop with degenerative disc disease, especially if the condition leads to nerve compression or damage in the lumbar spine (lower back). Foot drop refers to difficulty lifting the front part of the foot due to weakness or paralysis of the muscles involved in dorsiflexion.
Choice D Reason:
Intermittent pain is correct. Yes, intermittent pain is a hallmark symptom of degenerative disc disease. Pain may vary in intensity and may worsen with certain movements or activities. Individuals with DDD may experience episodes of acute pain, as well as chronic, persistent discomfort.
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