A nurse is planning care for a client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?
Encourage fluid intake at and between meals.
Cleanse the perineum from back to front.
Offer the client the bedpan every 2 hours.
Obtain a prescription for an indwelling urinary catheter.
The Correct Answer is A
A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.
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Correct Answer is B
Explanation
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B. Instructing the client to get up slowly while turning their entire body helps to reduce vertigo symptoms by minimizing head movement, which can trigger or worsen dizziness in Meniere’s disease.
C. Driving is not recommended during symptomatic periods of vertigo, as it could be unsafe.
D. The logroll technique is typically used for clients with spinal issues rather than vertigo management in Meniere’s disease.
Correct Answer is B
Explanation
A. While monitoring serum electrolytes is important, it is secondary to assessing for immediate life-threatening conditions.
B. Monitoring for signs of shock is the priority, as Addisonian crisis can lead to severe hypotension and shock, which requires immediate intervention.
C. Monitoring daily weights can help assess fluid status but is not critical in the context of an impending crisis.
D. Monitoring intake and output is important for overall assessment but does not directly address the immediate risks associated with Addisonian crisis.