A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

Limit fluid intake to prevent incontinence

Provide regular perineal care to prevent skin breakdown

Administer hypotonic IV fluids

Teach Kegel exercises to strengthen the pelvic floor

Answer and Explanation

The Correct Answer is B

Choice A: Limit fluid intake to prevent incontinence. This is incorrect because limiting fluid intake can lead to dehydration, urinary tract infections, and kidney stones. Fluid intake should be adequate to maintain hydration and flush out bacteria from the urinary tract.

Choice B: Provide regular perineal care to prevent skin breakdown. This is correct because reflex incontinence can cause urine leakage and skin irritation, which can increase the risk of infection and pressure ulcers. Regular perineal care can help keep the skin clean and dry, and prevent complications.

Choice C: Administer hypotonic IV fluids. This is incorrect because hypotonic IV fluids can cause fluid overload, hyponatremia, and cerebral edema. Hypotonic IV fluids are not indicated for clients with reflex incontinence.

Choice D: Teach Kegel exercises to strengthen the pelvic floor. This is incorrect because Kegel exercises are effective for clients with stress or urge incontinence, but not for clients with reflex incontinence. Reflex incontinence is caused by a loss of voluntary control over the bladder due to a spinal cord injury, and Kegel exercises cannot restore this function.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Plantar flexion is the movement of the foot that points the toes downward. It is not a test for gait, but rather a test for muscle strength and nerve function in the lower leg.

Choice B reason: Romberg is a test for balance and coordination that involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed. If the client sways or falls when their eyes are closed, it indicates a problem with their proprioception, which is the sense of position and movement of the body. Ataxia is a condition that affects proprioception and causes impaired gait, so Romberg is an appropriate test for it.

Choice C reason: Achilles reflex is the contraction of the calf muscle when the Achilles tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the lower leg.

Choice D reason: Patellar reflex is the extension of the lower leg when the patellar tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the upper leg.

A. Nurses performing duties outside of the nurses' typical job description B. A plan for comprehensive practice drills C. Identification of resources to meet anticipated needs for food, water, and supplies D. An internal and external communication plan E. Discharge all surgical clients who are one day or more post-op

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Nurses performing duties outside of the nurses' typical job description is a component that should include nurses. In a disaster situation, nurses may have to assume roles and responsibilities that are beyond their usual scope of practice, such as triage, first aid, or mass casualty management. Nurses should be trained and prepared to perform these duties safely and effectively.

Choice B reason: A plan for comprehensive practice drills is a component that should include nurses. Practice drills are essential for testing and improving the disaster plan, as well as enhancing the skills and confidence of the staff. Nurses should participate in regular and realistic drills that simulate different types of disasters and scenarios.

Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component that should include nurses. In a disaster situation, the demand for resources may exceed the supply, and the availability of resources may be disrupted or limited. Nurses should be involved in identifying and prioritizing the essential resources that are needed to provide care and support to the clients and staff.

Choice D reason: An internal and external communication plan is a component that should include nurses. In a disaster situation, communication is vital for coordinating actions, sharing information, and providing updates. Nurses should be aware of the communication channels and protocols that are used within and outside the hospital, such as radios, phones, or social media.

Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component that should include nurses. This is not a realistic or appropriate strategy for reducing the hospital's occupancy or workload in a disaster situation. Discharging surgical clients who are still recovering may compromise their health outcomes and increase their risk of complications or readmission.

View Question and Answer

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

A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client has ataxia. Which test does the nurse use to gain more information about this client's gait?

Correct Answer is B

Explanation

The hospital's Emergency Operations Committee is working on their disaster plan. In which components should nurses be included? SELECT ALL THAT APPLY

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is developing an activity plan for a client. The nurse should recognize that which activity plan would best conserve the client's energy without compromising physical or mental health.

A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

The community health nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?

A nurse is teaching a client who has a new prescription for sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century.

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?

The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY