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:

Chewing the tablet before swallowing is not the correct method of administration for Sumatriptan (Imitrex) tablets. These tablets are designed to be swallowed whole. Chewing them could affect the medication’s efficacy and absorption.

Choice B reason:

“If you experience chest pain, call your physician immediately.” This instruction is crucial because Sumatriptan can cause serious cardiovascular side effects, including chest pain, which may indicate a heart attack or other serious condition. Clients need to be aware of this potential side effect and seek immediate medical attention if it occurs.

Choice C reason:

Taking Sumatriptan daily to prevent headaches is incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use as a preventive medication. Using it daily could lead to medication overuse headaches and other adverse effects.

Choice D reason:

“Repeat dose in 1 hour for unrelieved headache” is partially correct but incomplete. The correct instruction is to repeat the dose after 2 hours if the headache is not relieved, up to a maximum of two doses in 24 hours. Clients should follow the specific dosing instructions provided by their healthcare provider.

A. Hypertension B. Tinnitus C. Hypotension D. Tachycardia

Correct Answer is A

Explanation

Choice A reason:

Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.

Choice B reason:

Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.

Choice C reason:

Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.

Choice D reason:

Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.

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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

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