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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?

A.

Encourage fluid intake at and between meals.

B.

Cleanse the perineum from back to front.

C.

Offer the client the bedpan every 2 hours.

D.

Obtain a prescription for an indwelling urinary catheter.

Answer and Explanation

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. Impaired production of GH is most likely the cause of short stature, as growth hormone plays a critical role in growth and development during childhood.

C. Lack of ACTH affects adrenal hormone production but does not directly lead to short stature or delayed menarche.

D. Impaired production of T3 and T4 would affect metabolism and growth but is less likely to be the primary cause of the symptoms presented compared to growth hormone deficiencies.

Correct Answer is B

Explanation

A. Profound hypocalcemia is not associated with hyperthyroidism; it is more common in hypoparathyroidism.

B. Thyroid Storm is a life-threatening complication of hyperthyroidism, characterized by high fever, tachycardia, hypertension, and altered mental status. It requires immediate medical intervention to prevent serious outcomes.

C. Diabetes Insipidus is unrelated to hyperthyroidism and typically occurs due to antidiuretic hormone dysfunction.

D. Severe hypotension is not a typical complication of hyperthyroidism; rather, hypertension is more likely due to increased metabolic rate and cardiac output.

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