A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?
Urge incontinence
Weight gain
Rectal distention
Dribbling of urine
The Correct Answer is D
A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.
B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.
C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.
D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While antipsychotics may slightly increase stroke risk in older adults, the primary concern for dementia clients is often fall risk.
B. Many sedative and antipsychotic medications increase the risk of falls, especially in older adults, due to their sedating effects and impact on balance.
C. These medications do not typically cause an increase in blood pressure; they may actually lower it, contributing to dizziness and fall risk.
D. Infection risk is not directly increased by these medications, although fall injuries can complicate recovery and care.
Correct Answer is A
Explanation
A. The location of burns on the face, neck, and upper extremities is critical as it can compromise the airway, making it a priority.
B. Age is important for overall risk assessment, but airway compromise takes precedence.
C. The cause of the burn (e.g., chemical, electrical) impacts treatment but is secondary to addressing airway risks in this scenario.
D. Associated medical history provides context but does not supersede the immediate concerns related to the burn location and airway.
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