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 C

Explanation

Choice A reason:

“It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” While this response acknowledges the client’s feelings, it does not provide specific information about the benefits of cardiac rehabilitation. The client needs to understand how rehabilitation can help them recover and improve their quality of life.

Choice B reason:

“Diet and exercise are good for you and good for your heart.” This statement is true but too general. It does not address the client’s specific concerns about the purpose and benefits of cardiac rehabilitation. The client needs more detailed information about how the program can help them.

Choice C reason:

“Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” This response directly addresses the client’s concerns and provides clear information about the benefits of cardiac rehabilitation. It explains that while the damage cannot be reversed, rehabilitation can help the client regain strength, improve cardiovascular health, and safely return to their daily activities.

Choice D reason:

“Your doctor is the expert here, and I’m sure they would only recommend what is best for you.” While this statement supports the doctor’s recommendation, it does not provide the client with specific information about the benefits of cardiac rehabilitation. The client needs to understand how the program can help them personally.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who questions the need for cardiac rehabilitation, stating, “My heart is permanently damaged from the heart attack, so what’s the point of cardiac rehabilitation?” Which response should the nurse prioritize?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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