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?

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

Use water with no soap to prevent skin irritation.

Don sterile gloves to prevent infection.

Discard the washcloth after cleansing the urethral meatus.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d.

Choice A rationale:

Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.

Choice B rationale:

Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.

Choice C rationale:

While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.

Choice D rationale:

Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.

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Correct Answer is D

Explanation

Choice A rationale:

Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.

Choice B rationale:

Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.

Choice C rationale:

Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.

Choice D rationale:

Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.

A. Instilling an ophthalmic ointment for a client who has a corneal abrasion B. Inserting an NG tube for a client who needs continuous enteral feedings C. Changing a central venous catheter dressing for a client who is receiving IV therapy D. Administering an IM injection to a client who has bacterial pneumonia

Correct Answer is C

Explanation

Changing a central venous catheter dressing for a client who is receiving IV therapy. Sterile gloves are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected. A central venous catheter is inserted into a large vein near the heart and can be a source of infection if not handled properly. Changing the dressing requires sterile gloves to prevent contamination of the catheter site and the bloodstream.

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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?

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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?