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
A. Quadriplegia, or tetraplegia, is typically associated with injuries at or above the C4 level, not T2-T3.
B. A T2-T3 spinal cord injury can lead to loss of sensation and motor function below the level of injury, affecting the thoracic region and lower body.
C. Hemiplegia, which refers to paralysis on one side of the body, is typically due to brain injuries or strokes, not spinal cord injuries.
D. While bladder control may be affected, the most direct impact of T2-T3 injury is the loss of sensation and motor function below that level.
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.