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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Osmotic edema refers to fluid shifts due to changes in osmotic gradients (as seen in conditions like hyponatremia), not the inflammatory process of meningitis.
B.While inflammation is a key part of the body's response in meningitis, the edema is not a result of generalized whole-body inflammation. The edema is more directly linked to local inflammatory reactions in the brain triggered by the pathogen’s by-products.
C.Bacterial cell walls, endotoxins, and other components released by the bacteria directly stimulate inflammation, causing the breakdown of the BBB and allowing fluid and inflammatory cells to leak into the brain tissue.
D.This description is more aligned with the pathophysiology of conditions like hydrocephalus rather than meningitis. In meningitis, cerebral edema is primarily due to the inflammatory response, not abnormal CSF flow.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.