A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?
A Drain the bladder with a clean intermittent catheter every hour
B Decrease fluid intake
C Observe the urine for a foul odor
D Keep an indwelling catheter in place at all times
The Correct Answer is A
Choice A Rationale: The nurse will include instructions on draining the bladder with a clean intermittent catheter at appropriate intervals to prevent urinary retention and complications. This should be done every 3 to 6 hours, depending on the amount of fluid intake and output.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.
Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.
Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.
Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.
Correct Answer is ["C","E"]
Explanation
Choice A Rationale: Hypertension is not a sign of neurogenic shock, but rather of autonomic dysreflexia, a life-threatening condition that can occur in patients with spinal cord injury above T6.
Choice B Rationale: Rapidly elevating temperature is also a sign of autonomic dysreflexia, not neurogenic shock. Neurogenic shock can cause hypothermia due to impaired thermoregulation.
Choice C Rationale: Bradycardia is a sign of neurogenic shock due to the loss of sympathetic stimulation to the heart, which normally increases the heart rate and contractility.
Choice D Rationale: Fixed and dilated pupils are a sign of brain death, not neurogenic shock. Neurogenic shock can cause miosis (constriction of the pupils) due to unopposed parasympathetic stimulation.
Choice E Rationale: Hypotension is a sign of neurogenic shock due to the vasodilation and decreased venous return caused by the loss of sympathetic tone.
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