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

Limited fluid intake to prevent incontinence.

Administration of antispasmodic medication.

Kegel exercises to strengthen the pelvic floor.

Regular perineal care to prevent skin breakdown.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.

Choice B reason:

Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.

Choice C reason:

Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.

Choice D reason:

Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.

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Correct Answer is D

Explanation

Choice A reason:

Seasonal allergies, also known as allergic rhinitis, can be exacerbated by air pollutants, including ozone. However, individuals with asthma are more severely affected by ozone exposure. Ozone can trigger asthma attacks and worsen symptoms, making it a more critical concern for those with asthma.

Choice B reason:

Mitral valve disease affects the heart’s mitral valve and can lead to symptoms such as shortness of breath and fatigue. While air pollution can impact cardiovascular health, ozone specifically poses a greater risk to individuals with respiratory conditions like asthma rather than those with mitral valve disease.

Choice C reason:

Nasal polyps are noncancerous growths in the nasal passages or sinuses that can cause breathing difficulties and chronic sinus infections. Although air pollutants can irritate the nasal passages, individuals with asthma are more vulnerable to the harmful effects of ozone, which can exacerbate their respiratory symptoms.

Choice D reason:

Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to difficulty breathing. Ozone exposure can significantly worsen asthma symptoms, trigger asthma attacks, and reduce lung function. Therefore, individuals with asthma are especially vulnerable to the effects of ozone.

A. Develop a survey on teen pregnancies B. Hold a focus group to discuss immunizations C. Perform a windshield survey D. Interview the elderly at the senior’s center

Correct Answer is C

Explanation

Choice A reason:

Developing a survey on teen pregnancies is important for understanding the prevalence and factors contributing to teen pregnancies in the community. However, it is not the most immediate priority intervention. Surveys are useful for data collection but do not provide immediate insights into the overall community health needs.

Choice B reason:

Holding a focus group to discuss immunizations is valuable for gathering community input and addressing concerns about vaccinations. While this is an important public health activity, it is more specific and does not provide a comprehensive overview of the community’s health needs.

Choice C reason:

Performing a windshield survey is a priority intervention for a public health nurse assigned to a new community. This type of survey involves systematically observing the community to gather information about its overall health status, resources, and needs. It provides a broad overview that can inform more targeted interventions and programs.

Choice D reason:

Interviewing the elderly at the senior’s center is important for understanding the specific needs of this population group. However, it is a more focused intervention and does not provide a comprehensive assessment of the entire community’s health needs.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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