A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

Urge incontinence

Weight gain

Rectal distention

Dribbling of urine

Answer and Explanation

The Correct Answer is D

A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.

B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.

C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.

D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.

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Correct Answer is B

Explanation

A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.

B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.

C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.

D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.

A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Place the client in a sitting position. D. Check the client's bladder for distention.

Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

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A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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