The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.
What would the nurse emphasize about catheter care? (Select All that Apply.)

You will have weekly appointments at the physician's office to change the catheter.

Sexual intimacy is not recommended with a catheter.

Underwear should not be worn with any catheter.

You will need to empty your leg bag every 4 hours or more frequently, depending on your oral intake.

Foul-smelling, cloudy urine should be reported to the physician immediately.

Answer and Explanation

Correct Answer : D,E

Choice A rationale

Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.

Choice B rationale

Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.

Choice C rationale

Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.

Choice D rationale

Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.

Choice E rationale

Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.

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Correct Answer is A

Explanation

Choice A rationale

Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.

Choice B rationale

Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.

Choice C rationale

Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.

Choice D rationale

Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .

A. Automatisms associated with this type of seizure. B. The client may have been exposed to a neurotoxin. C. An electrolyte imbalance, likely hyponatremia. D. A reversible adverse effect of anticonvulsant drugs.

Correct Answer is A

Explanation

Choice A rationale

Automatisms, such as eye blinking and lip smacking, are repetitive, involuntary movements commonly associated with absence seizures. They occur due to brief interruptions in consciousness during seizure activity without major motor involvement.

Choice B rationale

Neurotoxin exposure typically presents with symptoms like weakness, ataxia, and autonomic dysfunction. Increased eye blinking and lip smacking are not specific to neurotoxin-related neurological damage or poisoning.

Choice C rationale

Hyponatremia causes confusion, lethargy, and muscle cramps due to electrolyte disturbance affecting cellular function, but it does not cause specific automatisms like eye blinking or lip smacking in seizure-related conditions.

Choice D rationale

Reversible adverse effects of anticonvulsants often include sedation or cognitive slowing. Automatisms such as blinking and smacking are not typically linked to the pharmacological effects of anticonvulsants.

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The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)

Nursing Test Bank

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Correct Answer is A

Explanation

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The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.
What would the nurse emphasize about catheter care? (Select All that Apply.)