A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
(Select All that Apply.)

"It will be necessary to take a stool softener to keep you from becoming constipated."

"Suprapubic catheterization might have to be done if you are unable to catheterize yourself."

"You will need to learn how to do self-intermittent catheterization to drain your bladder."

"Do not drink fluids excessively as this may cause diarrhea."

"To achieve a bowel movement, dally digital stimulation will need to be done."

Answer and Explanation

Correct Answer : A,B,C,E

Choice A Reason:

"It will be necessary to take a stool softener to keep you from becoming constipated." This instruction is correct. Individuals with spinal cord injuries often experience bowel dysfunction, including constipation, due to decreased mobility and impaired bowel function. Stool softeners can help soften the stool and facilitate easier bowel movements, reducing the risk of constipation and associated complications such as fecal impaction.

Choice B Reason:

"Suprapubic catheterization might have to be done if you are unable to catheterize yourself." This instruction is correct. Suprapubic catheterization involves the insertion of a catheter through the abdominal wall directly into the bladder to drain urine. It may be necessary if the client is unable to perform intermittent catheterization independently or if other methods of bladder management are ineffective or contraindicated.

Choice C Reason:

"You will need to learn how to do self-intermittent catheterization to drain your bladder." This instruction is correct. Self-intermittent catheterization involves inserting a catheter into the bladder to drain urine at regular intervals. It is a commonly used method of bladder management for individuals with spinal cord injuries to prevent urinary retention and bladder distention.

Choice D Reason:

"Do not drink fluids excessively as this may cause diarrhea," is not typically included in bowel and bladder management instructions for individuals with spinal cord injuries. Hydration is important for overall health and may help prevent complications such as urinary tract infections, kidney stones, and constipation. Therefore, option D is not appropriate for inclusion in the teaching for a client with a complete spinal cord injury.

Choice E Reason:

"To achieve a bowel movement, daily digital stimulation will need to be done." This instruction is incorrect. Digital stimulation involves gently stimulating the rectum with a lubricated gloved finger to initiate a bowel movement. It can help individuals with spinal cord injuries who have neurogenic bowel dysfunction to stimulate bowel motility and facilitate bowel evacuation.

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Correct Answer is A

Explanation

Choice A Reason:

MS hug is appropriate. The "MS hug" is a colloquial term used to describe a sensation of tightness, pressure, or squeezing around the torso or chest area experienced by some individuals with multiple sclerosis (MS). It is caused by spasms or contractions of the intercostal muscles (muscles between the ribs) or the diaphragm due to lesions in the spinal cord disrupting nerve signals. This sensation can be uncomfortable or painful for the individual.

Choice B Reason:

Lhermitte's sign is inappropriate. Lhermitte's sign is a common symptom experienced by individuals with MS but it presents differently. It is characterized by an electric shock-like sensation that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is caused by damage to the spinal cord's myelin sheath, leading to abnormal nerve signal transmission.

Choice C Reason:

Paroxysmal spasms is inappropriate. Paroxysmal spasms are sudden, involuntary muscle contractions or jerking movements that can occur in various parts of the body. While spasms are common in MS, they are not specifically associated with the sensation of tightness around the torso as described in the scenario.

Choice D Reason:

Trigeminal neuralgia is inappropriate. Trigeminal neuralgia is a condition characterized by sudden, severe facial pain often described as stabbing or electric shock-like. It is caused by irritation or damage to the trigeminal nerve, which is responsible for facial sensation. While individuals with MS may experience trigeminal neuralgia, it typically does not present with a tightening feeling around the torso.

A. Repeating the same question over and over B. Awareness of COPD manifestations C. Anxiety and restlessness D. Motivation and engagement of the client

Correct Answer is D

Explanation

Choice A Reason:

Repeating the same question over and over is incorrect. Repeating the same question over and over is not a desired outcome of client education. It may indicate confusion or cognitive impairment rather than effective learning and understanding of COPD management.

Choice B Reason:

Awareness of COPD manifestations is incorrect. This is a desirable outcome of client education. Increasing the client's awareness of COPD manifestations, such as dyspnea, coughing, and sputum production, can help them recognize exacerbations early and take appropriate action to manage their condition.

Choice C Reason:

Anxiety and restlessness is incorrect. Anxiety and restlessness are not desired outcomes of client education. While anxiety is common in individuals with COPD due to the chronic nature of the condition and its impact on daily activities, education should aim to reduce anxiety by providing information and strategies for coping with COPD-related symptoms and challenges.

Choice D Reason:

Motivation and engagement of the client is correct. This is a desirable outcome of client education. Motivating and engaging the client in their own care empowers them to take an active role in managing their COPD and improving their quality of life. Education should provide information, support, and encouragement to help the client feel motivated and engaged in self-management strategies.

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A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has multiple sclerosis and reports a tightening feeling around their torso. Which of the following conditions should the nurse recognize this finding indicates?

Correct Answer is A

Explanation

A nurse is providing a client who has COPD with education regarding adapting their behavior. Which of the following describes an anticipated outcome following education of the client?

Correct Answer is D

Explanation

A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the following provider prescriptions should the nurse anticipate? (Select all that apply.) (Select All that Apply.)

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A nurse is caring for a client who has chronic respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect with this client?

A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
(Select All that Apply.)