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A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

A.

Use water with no soap to prevent skin irritation.

B.

Discard the washcloth after cleansing the urethral meatus.

C.

Don sterile gloves to prevent infection.

D.

Wash the penis from the scrotum to the tip using a spiral motion.

Answer and Explanation

The Correct Answer is B

A. While avoiding harsh soap is important, using water alone may not adequately clean the area.

B. After cleaning the urethral meatus, the nurse should discard the washcloth or use a different part of it to prevent the spread of bacteria.

C. Clean gloves are typically sufficient unless the procedure involves a sterile environment.

D. The penis should be cleaned from the tip to the base (proximal to distal) to reduce the risk of introducing bacteria.


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Related Questions

Correct Answer is D

Explanation

A. Belching: A common, benign post-procedure occurrence.

B. Sore throat: Expected due to endoscope insertion.

C. Flatulence: Typically benign and not concerning post-EGD.

D. Abdominal pain: May indicate a perforation or other serious complication and requires immediate evaluation.

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings

Sprain

Fracture

Dislocation

Ecchymosis

✅

✅

✅

Pain level

✅

✅

✅

Edema

✅

✅

✅

Sensation

✅

✅

Rationale:

Ecchymosis (bruising):

Sprain: Common due to soft tissue damage.

Fracture: Frequently present due to bone and soft tissue injury.

Dislocation: Bruising often accompanies joint dislocation.

Pain level:

Sprain: Moderate pain, often exacerbated by movement.

Fracture: Pain is typically sharp and worsens with movement or weight-bearing.

Dislocation: Severe pain due to misalignment of the joint.

Edema:

Sprain: Common due to inflammation from ligament injury.

Fracture: Swelling is typical around the fracture site.

Dislocation: Edema occurs due to joint misalignment and tissue trauma.

Sensation (tingling):

Sprain: Nerve compression or irritation may cause tingling.

Fracture: Tingling can result from nerve involvement or swelling near the fracture site.

Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.

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