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A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program.
Which of the following findings indicates to the nurse the need to catheterize the client?

A.

Reflex incontinence

B.

Urge incontinence C. Nocturnal enuresis

C.

Suprapubic discomfort

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Reflex incontinence is a type of urinary incontinence that occurs when the person has no control over urination. They’re unable to feel when their bladder is full and can’t control the process of emptying it. This is often due to a brain or spinal cord injury that disrupts communication between these organs. However, this condition does not necessarily indicate the need for catheterization in a client with paraplegia who is already on an intermittent urinary catheterization program.

Choice B rationale:

Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. This condition can be caused by various factors, including neurological disorders, bladder abnormalities, and certain medications. While it can be a challenge for individuals with paraplegia, it does not directly indicate the need for catheterization.

Choice C rationale:

Nocturnal enuresis, or bedwetting, is involuntary urination while asleep. It’s a common condition, especially in young children, but it can affect individuals of any age. In the context of a client with paraplegia, nocturnal enuresis could be a symptom of a larger issue, such as a urinary tract infection or bladder dysfunction, but it does not directly indicate the need for catheterization. Choice D rationale:

Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale:

Wheezing Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), rather than being a symptom of hyperkalemia.

Choice B rationale:

Cerebral edema Cerebral edema, or swelling in the brain, is not typically a symptom of hyperkalemia. It’s more commonly associated with traumatic brain injury, stroke, or brain tumors.

Choice C rationale:

Decreased deep tendon reflexes Decreased deep tendon reflexes can be a symptom of hyperkalemia. Hyperkalemia is a condition in which the potassium levels in your blood get too high. Potassium helps nerves send signals between your brain and the rest of your body. High levels of potassium can affect nerve function, leading to symptoms such as muscle weakness or decreased reflexes. Choice D rationale:

Hypoactive bowel sounds Hypoactive bowel sounds, or decreased or absent bowel sounds, are typically associated with conditions affecting the gastrointestinal system, such as ileus or bowel obstruction. They are not typically a symptom of hyperkalemia.

Correct Answer is B,C,A,D

Explanation

B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.

C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.

A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.

D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.

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