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 B

Explanation

Choice A reason:

Closing the school for 6 weeks is an extreme measure that is not typically warranted for managing influenza outbreaks. Public health guidelines usually recommend temporary closures or other measures to control the spread of infection, but a 6-week closure is excessive and disruptive.

Choice B reason:

Education regarding respiratory and hand hygiene is an appropriate and effective action to help control the spread of influenza. Teaching students and staff about proper handwashing techniques, respiratory etiquette, and other preventive measures can significantly reduce the transmission of the virus. This approach empowers the school community to take proactive steps in preventing further infections.

Choice C reason:

Discipline in the school setting for improper handwashing is not an appropriate response. While it is important to encourage proper hygiene practices, using disciplinary measures can create a negative environment and may not effectively promote behavior change. Education and positive reinforcement are more effective strategies.

Choice D reason:

Running a mandatory flu clinic can be beneficial, but it is not the most immediate or appropriate action in response to an outbreak. Flu clinics are typically part of broader vaccination efforts and may not address the immediate need to control the current outbreak. Education on hygiene practices is a more immediate and practical response.

A. Restrict drinking fluids before and during meals. B. Plan medication doses to occur before meals. C. Increase the amount of fat and carbohydrates in meals. D. Eat three large meals per day.

Correct Answer is B

Explanation

Choice A reason:

Restricting drinking fluids before and during meals is not an appropriate suggestion for improving nutritional status. While it might help prevent early satiety in some cases, it does not address the underlying issues related to Myasthenia gravis, such as muscle weakness affecting chewing and swallowing.

Choice B reason:

Planning medication doses to occur before meals is a crucial strategy for clients with Myasthenia gravis. Medications such as anticholinesterase agents can help improve muscle strength, making it easier for the client to chew and swallow food. This approach can enhance the client’s ability to consume adequate nutrition during meals.

Choice C reason:

Increasing the amount of fat and carbohydrates in meals might help with caloric intake, but it does not address the specific challenges faced by clients with Myasthenia gravis. The focus should be on strategies that improve the client’s ability to eat effectively, rather than just altering the macronutrient composition of meals.

Choice D reason:

Eating three large meals per day can be challenging for clients with Myasthenia gravis due to muscle fatigue. Smaller, more frequent meals are often recommended to help manage energy levels and ensure adequate nutrition without overwhelming the client.

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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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