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A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's complication? (Select all that apply.)
- A. Pour warm water over the perineum.
- B. Provide a diet high in fluids and fiber.
- C. Administer daily tap water enemas.
- D. Massage the abdomen from left to right.
- E. Perform manual disimpaction.
Correct Answer: B,D,F
Rationale: For a flaccid bowel due to a lower motor neuron injury, a bowel program including a high-fluid and high-fiber diet, stool softeners, and manual disimpaction if needed is effective. Pouring warm water, daily enemas, and abdominal massage are not appropriate.
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A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)
- A. Perform range-of-motion (ROM) exercises for the hip joint.
- B. Reposition the client off of the reddened areas.
- C. Get the client out of bed and into a chair once a day.
- D. Obtain a low-air-loss mattress to minimize pressure.
- E. Apply a barrier cream to the reddened areas.
Correct Answer: B,D
Rationale: Repositioning and using a low-air-loss mattress relieve pressure on reddened areas. Rubbing, barrier creams, ROM exercises, and sitting in a chair do not address pressure relief effectively.
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
- A. Take warm baths to promote muscle relaxation.
- B. Avoid people with upper respiratory illnesses.
- C. Relying on a walker will weaken your gait.
- D. Take prescribed medication only when symptoms occur.
Correct Answer: B
Rationale: Clients taking cyclophosphamide and methylprednisolone are immunocompromised and should avoid people with upper respiratory illnesses to prevent infections. Warm baths may help but are not the priority, relying on a walker does not necessarily weaken gait, and medications should be taken as prescribed, not only when symptoms occur.
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?
- A. Screen for metal implants or devices.
- B. Implement nothing by mouth (NPO) status for 8 hours.
- C. Administer a sedative to reduce anxiety.
- D. Ensure the client has an empty bladder.
Correct Answer: A
Rationale: Screening for metal implants or devices is critical before an MRI to prevent harm due to magnetic fields. NPO status, sedation, and bladder emptying are not typically required unless specified.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
- A. I will explore other ways besides intercourse to please my partner.
- B. I will not be able to have an erection because of my injury.
- C. Ejaculation may not be as predictable as before.
- D. I may urinate with ejaculation but this will not cause infection.
- E. I should be able to have an erection with stimulation.
Correct Answer: C,D,E
Rationale: Men with injuries above T6 can often have reflex erections with stimulation. Ejaculation may be less predictable and mixed with urine, which is sterile and does not cause infection. Exploring alternative intimacy methods is also appropriate.
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?
- A. Only lift items that are 10 pounds or less.
- B. You must wear a brace throughout the healing process.
- C. You must remain in bed for 3 weeks after surgery.
- D. You are prescribed medications to prevent rejection.
Correct Answer: B
Rationale: Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process to stabilize the spine. The other options are incorrect: lifting restrictions may vary, bed rest for 3 weeks is not typically required, and rejection medications are not needed for spinal fusion.