A nurse in a rehabilitation facility is preparing a discharge plan for a client who has paraplegia. Which of the following interventions should the nurse include in the plan?
Recommend that the client adhere to a low-fiber diet.
Recommend that the client avoid the influenza vaccine.
Instruct the client to empty their bladder every 2 hr during the day.
Instruct the client to change positions every 3 hr when sitting in a chair.
The Correct Answer is C
A. Clients with paraplegia are at risk for constipation due to decreased mobility. A low-fiber diet would worsen bowel issues. A high-fiber diet with adequate fluids is typically recommended to maintain regular bowel function.
B. Clients with paraplegia are not contraindicated for the influenza vaccine; in fact, vaccination is important to prevent respiratory infections, which can be more serious in individuals with limited mobility.
C. Instructing the client to empty their bladder every 2 hours helps prevent urinary retention and reduces the risk of urinary tract infections, which are common complications in clients with paraplegia due to impaired bladder function.
D. Instructing the client to change positions every 3 hours when sitting in a chair is insufficient for pressure injury prevention. Clients should be encouraged to shift weight every 15–30 minutes and reposition regularly to prevent skin breakdown.
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Related Questions
Correct Answer is A
Explanation
A. Clients transferring from acute care to a rehabilitation facility often have complex needs, multiple providers, and ongoing treatments that require careful coordination. A case manager can facilitate communication, ensure continuity of care, and arrange resources for a safe transition.
B. A client discharged after a minor outpatient procedure typically has simple, short-term needs and may not require case management.
C. Requesting a provider's note is an administrative task and does not involve complex care coordination.
D. Requesting a change in pain medication is a clinical concern that should be addressed by the primary provider or nurse, but it does not necessitate case management for continuity of care.
Correct Answer is D
Explanation
A. Postoperative pain management is important for comfort and recovery, but it is not immediately life-threatening.
B. An oxygen saturation of 90% in a client with COPD is slightly low but may be within their baseline; it requires monitoring but is not the most urgent concern.
C. The client requesting clear liquids after TPN discontinuation is a comfort and nutritional issue, not a priority safety concern.
D. A capillary refill of 4 seconds in a client who had a cardiac catheterization indicates impaired peripheral perfusion, which may signal arterial compromise or vascular occlusion. This is an urgent finding requiring immediate assessment and intervention to prevent tissue ischemia or necrosis, making it the highest priority.
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