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 A

Explanation

A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.

A. A red, dull, thick, and immobile tympanic membrane. B. A transparent and clear tympanic membrane. C. A pearly colored tympanic membrane. D. A pink colored tympanic membrane.

Correct Answer is A

Explanation

A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.

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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?

Nursing Test Bank

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