A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
Limited fluid intake to prevent incontinence.
Administration of antispasmodic medication.
Kegel exercises to strengthen the pelvic floor.
Regular perineal care to prevent skin breakdown.
The Correct Answer is D
Choice A reason:
Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.
Choice B reason:
Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.
Choice C reason:
Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.
Choice D reason:
Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.
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Correct Answer is B
Explanation
Choice A reason:
The security phase is not a recognized phase in the National Response Framework. The framework focuses on preparedness, response, recovery, and mitigation phases. Security measures are integrated into these phases but are not a standalone phase.
Choice B reason:
The mitigation phase involves actions taken to reduce the impact of disasters before they occur. This includes identifying at-risk populations, educating residents about evacuation routes, and establishing emergency shelters. These proactive measures help minimize the potential damage and enhance community resilience.
Choice C reason:
The response phase involves actions taken during and immediately after a disaster to ensure safety and provide emergency assistance. While important, the activities described in the question are more aligned with mitigation efforts that occur before a disaster strikes.
Choice D reason:
The practice phase is not a recognized phase in the National Response Framework. However, preparedness activities, including drills and exercises, are part of the overall framework to ensure readiness for potential disasters.
Correct Answer is ["B","E"]
Explanation
Choice A reason:
“I may experience urinary incontinence.” This statement is correct. Urinary incontinence is a common symptom of MS due to the disease’s impact on the nervous system. The client does not need additional teaching regarding this statement.
Choice B reason:
“I should not exercise because this may trigger an exacerbation.” This statement indicates a need for additional teaching. Regular exercise is beneficial for individuals with MS and can help improve strength, mobility, and overall well-being. The nurse should educate the client on safe and appropriate exercise routines.
Choice C reason:
“I need to check the water temperature before I take a bath.” This statement is correct. Clients with MS may have impaired sensation and are at risk for burns if the water is too hot. Checking the water temperature is a necessary precaution.
Choice D reason:
“I may experience visual disturbances.” This statement is correct. Visual disturbances, such as blurred vision or double vision, are common symptoms of MS. The client does not need additional teaching regarding this statement.
Choice E reason:
“I should alternate the eye patch every other day to help with the double vision.” This statement indicates a need for additional teaching. While using an eye patch can help manage double vision, it should be alternated more frequently, typically every few hours, to prevent strain on the covered eye.