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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Prodrome is incorrect. The prodrome phase occurs before the onset of the headache and can last for hours to days. During this phase, individuals may experience subtle changes that serve as warning signs of an impending migraine attack. Common prodromal symptoms include fatigue, mood changes, food cravings, increased thirst, and heightened sensitivity to light or sound. Tingling of the face and blind spots in the eyes are not typically associated with the prodrome phase.
Choice B Reason:
Aura is correct. The aura phase of a migraine typically occurs before or during the headache phase and involves neurological symptoms. Aura symptoms can include visual disturbances such as blind spots, zigzag lines, or flashing lights, as well as sensory symptoms like tingling or numbness, often starting in one part of the body and spreading gradually. The tingling of the face and blind spots in the eyes described by the client are consistent with the aura phase of a migraine.
Choice C Reason:
Postdrome is incorrect. The postdrome phase occurs after the headache phase and can last for hours to days. During this phase, individuals may experience lingering symptoms such as fatigue, difficulty concentrating, mood changes, and muscle aches. While some individuals may experience visual disturbances during the postdrome phase, the tingling of the face and blind spots in the eyes described by the client are more characteristic of the aura phase.
Choice D Reason:
Headache is incorrect. The headache phase of a migraine is characterized by moderate to severe throbbing head pain, often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light or sound. While visual disturbances can occur during the headache phase, the tingling of the face and blind spots in the eyes described by the client precede the onset of headache, suggesting the aura phase rather than the headache phase.
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A Reason:
Asthma flare-ups during exercise is correct . Exercise-induced asthma is a common feature of nonallergic asthma. Physical activity can trigger bronchoconstriction and asthma symptoms in individuals with this type of asthma.
Choice B Reason:
Nasal inflammation is incorrect. Nasal inflammation is not typically a characteristic feature of nonallergic asthma. While nasal symptoms such as congestion, rhinorrhea (runny nose), and sneezing are common in allergic asthma due to the involvement of allergic rhinitis (hay fever), they are not typically prominent in nonallergic asthma. Nonallergic asthma primarily affects the lower airways (bronchi and bronchioles) rather than the upper airways (nose and throat). Therefore, nasal inflammation is not commonly associated with nonallergic asthma.
Choice C Reason:
No hypersensitivity to allergens is correct. Unlike allergic asthma, where exposure to allergens triggers asthma symptoms, individuals with nonallergic asthma do not have a hypersensitivity to allergens.
Choice D Reason:
Asthma flare-ups with NSAID administration is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can trigger asthma symptoms in some individuals with nonallergic asthma.
Choice E Reason:
Persistence of manifestations is correct. Nonallergic asthma tends to have persistent symptoms even in the absence of allergen exposure. Symptoms may occur regularly and may not have a clear seasonal pattern like allergic asthma.
Choice F Reason:
Positive response to corticosteroids is correct. Corticosteroids are often effective in managing nonallergic asthma. Individuals with this type of asthma typically respond well to corticosteroid treatment as part of their asthma management plan.
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