A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program.
Which of the following findings indicates to the nurse the need to catheterize the client?
Reflex incontinence
Urge incontinence
Nocturnal enuresis
Suprapubic discomfort
None
None
The Correct Answer is D
Choice A rationale:
Reflex incontinence is a type of urinary incontinence that occurs when the person has no control over urination. They’re unable to feel when their bladder is full and can’t control the process of emptying it. This is often due to a brain or spinal cord injury that disrupts communication between these organs. However, this condition does not necessarily indicate the need for catheterization in a client with paraplegia who is already on an intermittent urinary catheterization program.
Choice B rationale:
Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. This condition can be caused by various factors, including neurological disorders, bladder abnormalities, and certain medications. While it can be a challenge for individuals with paraplegia, it does not directly indicate the need for catheterization.
Choice C rationale:
Nocturnal enuresis, or bedwetting, is involuntary urination while asleep. It’s a common condition, especially in young children, but it can affect individuals of any age. In the context of a client with paraplegia, nocturnal enuresis could be a symptom of a larger issue, such as a urinary tract infection or bladder dysfunction, but it does not directly indicate the need for catheterization.
Choice D rationale:
Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
Correct Answer is A
Explanation
Choice A rationale:
Mitral valve stenosis is a condition characterized by a narrowing of the mitral valve in the heart, which can lead to a variety of symptoms. One of the most common symptoms of mitral valve stenosis is a heart murmur. This is due to the turbulent flow of blood caused by the narrowed valve. The murmur is typically heard during a physical examination when a healthcare provider listens to the heart with a stethoscope.
Choice B rationale:
Bradycardia, or a slower than normal heart rate, is not typically associated with mitral valve stenosis. While mitral valve stenosis can cause irregular heart rhythms, it does not typically cause the heart rate to slow down.
Choice C rationale:
Clubbing of the fingers is a physical symptom that involves changes in the areas under and around the nails and is typically associated with conditions that cause chronic low blood oxygen levels. While mitral valve stenosis can lead to shortness of breath and fatigue, it does not typically cause clubbing of the fingers.
Choice D rationale:
A barrel chest, characterized by an increased chest diameter, is typically associated with conditions that cause chronic overinflation of the lungs, such as chronic obstructive pulmonary disease (COPD). It is not a typical symptom of mitral valve stenosis.
In conclusion, while mitral valve stenosis can lead to a variety of symptoms, the most relevant to this question is a heart murmur. Other symptoms such as bradycardia, clubbing of the fingers, and a barrel chest are not typically associated with this condition.
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