A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
(Select All that Apply.)
"It will be necessary to take a stool softener to keep you from becoming constipated."
"Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
"You will need to learn how to do self-intermittent catheterization to drain your bladder."
"Do not drink fluids excessively as this may cause diarrhea."
"To achieve a bowel movement, dally digital stimulation will need to be done."
Correct Answer : A,B,C,E
Choice A Reason:
"It will be necessary to take a stool softener to keep you from becoming constipated." This instruction is correct. Individuals with spinal cord injuries often experience bowel dysfunction, including constipation, due to decreased mobility and impaired bowel function. Stool softeners can help soften the stool and facilitate easier bowel movements, reducing the risk of constipation and associated complications such as fecal impaction.
Choice B Reason:
"Suprapubic catheterization might have to be done if you are unable to catheterize yourself." This instruction is correct. Suprapubic catheterization involves the insertion of a catheter through the abdominal wall directly into the bladder to drain urine. It may be necessary if the client is unable to perform intermittent catheterization independently or if other methods of bladder management are ineffective or contraindicated.
Choice C Reason:
"You will need to learn how to do self-intermittent catheterization to drain your bladder." This instruction is correct. Self-intermittent catheterization involves inserting a catheter into the bladder to drain urine at regular intervals. It is a commonly used method of bladder management for individuals with spinal cord injuries to prevent urinary retention and bladder distention.
Choice D Reason:
"Do not drink fluids excessively as this may cause diarrhea," is not typically included in bowel and bladder management instructions for individuals with spinal cord injuries. Hydration is important for overall health and may help prevent complications such as urinary tract infections, kidney stones, and constipation. Therefore, option D is not appropriate for inclusion in the teaching for a client with a complete spinal cord injury.
Choice E Reason:
"To achieve a bowel movement, daily digital stimulation will need to be done." This instruction is incorrect. Digital stimulation involves gently stimulating the rectum with a lubricated gloved finger to initiate a bowel movement. It can help individuals with spinal cord injuries who have neurogenic bowel dysfunction to stimulate bowel motility and facilitate bowel evacuation.
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Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Decreased mucus production contributes to airway constriction: This statement is incorrect. Bronchospasm does not decrease mucus production; instead, it primarily affects the smooth muscles surrounding the bronchioles, leading to their constriction and narrowing of the airways. Increased mucus production, often accompanied by inflammation, can contribute to airway obstruction in conditions like asthma.
Choice B Reason:
Inflammation is reduced due to airway diameter: This statement is incorrect. Bronchospasm typically occurs in the setting of inflammation in conditions such as asthma. Constriction of the airways during bronchospasm exacerbates the inflammation and can further narrow the airways, leading to symptoms such as wheezing and dyspnea.
Choice C Reason:
Bronchospasm occurs when there is inflammation, edema, and excess mucus: This statement is partially correct. Bronchospasm often occurs in the presence of inflammation, edema, and excess mucus production, as seen in conditions like asthma. These factors contribute to airway hyperresponsiveness, leading to bronchospasm and airway narrowing.
Choice D Reason:
Airway obstruction occurs due to thinning mucus: This statement is incorrect. Airway obstruction in conditions like asthma is primarily due to bronchospasm, inflammation, and excessive mucus production, rather than thinning mucus. Thinning of mucus would not typically contribute to airway obstruction.
Correct Answer is C
Explanation
Choice A Reason:
Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.
Choice B Reason:
Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.
Choice C Reason:
Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.
Choice D Reason:
Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.
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