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 D
Explanation
A. Hypotension is not typically associated with adrenal cortex hyperfunction; in fact, patients may experience hypertension due to excess cortisol and aldosterone.
B. Dehydration is more common with adrenal insufficiency than hyperfunction, as excess hormone production often leads to fluid retention.
C. Hyponatremia is generally not a concern with adrenal cortex hyperfunction; clients may experience hypernatremia instead due to fluid retention.
D. Hypokalemia is a significant risk in clients with adrenal cortex hyperfunction, especially due to the effects of excessive aldosterone, which promotes sodium retention and potassium excretion.
Correct Answer is B
Explanation
A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.