A nurse is caring for a male client who has a spinal cord injury.
Which of the following techniques should the nurse use when providing perineal care?
Wash the penis from the scrotum to the tip using a spiral motion.
Use water with no soap to prevent skin irritation.
Don sterile gloves to prevent infection.
Discard the washcloth after cleansing the urethral meatus.
The Correct Answer is D
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using a 12-point font when printing written materials is helpful for readability, especially for individuals with visual impairments. However, this action alone does not necessarily promote meaningful learning. The content and presentation style are equally important.
Choice B rationale:
Presenting information using abstract concepts can be confusing, especially for older adults. Using concrete examples and simple language facilitates better understanding. Abstract concepts are more challenging to grasp, especially for individuals who might be experiencing cognitive decline.
Choice C rationale:
Connecting new information with the client's past experiences enhances learning and retention. Relating new knowledge to familiar situations or memories helps create cognitive associations, making it easier for the client to understand and remember the information. This technique is particularly effective in promoting learning among older adults.
Choice D rationale:
Speaking loudly when addressing the client is unnecessary and can be perceived as rude or patronizing. Clear and audible speech is essential, but shouting or raising the volume excessively is not respectful and does not enhance the learning experience.
Correct Answer is B
Explanation
Choice A rationale:
Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.
Choice B rationale:
Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.
Choice C rationale:
Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.
Choice D rationale:
Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.
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