A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Catheterize for residual urine after voiding.

Instruct the patient how to self-catheterize.

Assist the patient to the toilet every 2 hours.

Teach the patient to use the Credé method.

Answer and Explanation

The Correct Answer is B

A. Catheterize for residual urine after voiding: While catheterization for residual urine may be necessary in some cases, it is not the most appropriate long-term solution for managing a neurogenic reflexic bladder. It does not promote patient independence or long-term bladder health.

B. Instruct the patient how to self-catheterize: Self-catheterization empowers the patient to manage their bladder function independently and reduces the risk of urinary tract infections
associated with indwelling catheters. It is the preferred method for managing neurogenic bladder in patients with spinal cord injury.

C. Assist the patient to the toilet every 2 hours: While assisting the patient to the toilet at regular intervals may help prevent urinary accidents, it does not address the underlying issue of neurogenic bladder or promote long-term bladder management.

D. Teach the patient to use the Credé method: The Credé method involves applying manual pressure to the bladder to promote voiding. While it may be used in some situations, it is not the preferred method for managing neurogenic bladder, especially in patients with spinal cord injury.

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Correct Answer is A

Explanation

A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.

B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.

C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.

D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.

A. Auscultate the bowel sounds. B. Inspect the oral mucosa C. Check pupil reaction to light. D. Listen to the lung sounds.

Correct Answer is B

Explanation

A. Auscultate the bowel sounds: While gastrointestinal side effects such as nausea or
constipation can occur with phenytoin, auscultating bowel sounds is not a specific assessment related to its adverse effects.

B. Inspect the oral mucosa: Phenytoin is associated with gingival hyperplasia, a condition characterized by overgrowth of gum tissue. Therefore, inspecting the oral mucosa for signs of gum enlargement or other oral changes is important for evaluating adverse effects of phenytoin.

C. Check pupil reaction to light: Phenytoin does not typically affect pupil reaction to light. This assessment is more relevant for medications that act on the central nervous system or conditions affecting cranial nerve function.

D. Listen to the lung sounds: Phenytoin is not typically associated with respiratory side effects. Assessing lung sounds may be relevant in certain clinical situations, but it is not a specific assessment related to phenytoin adverse effects.

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A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is A

Explanation

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Correct Answer is B

Explanation

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