A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

A measure the calves for symmetry

B palpate the bladder

C Place a pillow between the knees and ankles

D Check the gag reflex

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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Correct Answer is D

Explanation

Choice A Rationale: Hemiplegia involves paralysis of one side of the body and is typically associated with brain injuries or lesions, not spinal cord injuries.

Choice B Rationale: Quadriplegia involves paralysis of all four limbs and is more commonly associated with higher spinal cord injuries, not T2-T3.

Choice C Rationale: Paresthesia refers to abnormal sensations, such as tingling or numbness, and may be present in various spinal cord injuries, but it is not a type of disability.

Choice D Rationale: Paraplegia involves paralysis of the lower extremities and trunk, and it is commonly associated with spinal cord injuries at the T2-T3 level.

A. A Drain the bladder with a clean intermittent catheter every hour B. B Decrease fluid intake C. C Observe the urine for a foul odor D. D Keep an indwelling catheter in place at all times

Correct Answer is A

Explanation

Choice A Rationale: Draining the bladder with a clean intermittent catheter at appropriate intervals is an essential part of managing urinary system complications in clients with spinal cord injury to prevent urinary retention and complications.

Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important for overall health.

Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.

Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications. Clean intermittent catheterization is often preferred.

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A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Correct Answer is D

Explanation

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?

Correct Answer is A

Explanation

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