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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.
B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.
C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.
Correct Answer is ["A","E","F"]
Explanation
A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.
B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.
C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.
D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.
E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.
F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.
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