A nurse is planning care for a client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Encourage fluid intake at and between meals.

Cleanse the perineum from back to front.

Offer the client the bedpan every 2 hours.

Obtain a prescription for an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is A

A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.

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Correct Answer is C

Explanation

A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.

A. Hypertension B. Family history C. Obesity D. Wearing sunglasses E. Increasing age

Correct Answer is ["A","B","C","E"]

Explanation

A. Hypertension has been associated with an increased risk of cataract development due to vascular changes that may affect the eye’s lens.
B. A family history of cataracts increases an individual's risk, as there may be a genetic predisposition to developing the condition.
C. Obesity is linked to cataracts, possibly due to metabolic effects that affect lens clarity over time.
E. Increasing age is a well-established risk factor for cataracts, as natural aging processes lead to changes in lens transparency.
D. Wearing sunglasses protects against UV exposure, which can lower the risk of cataracts, making it a preventive measure rather than a risk factor.

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A nurse is planning care for a client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

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