Nokea
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- A. Insert an indwelling urinary catheter.
- B. Stroke the medial aspect of the thigh.
- C. Use the Credé maneuver every 3 hours.
- D. Apply a Texas catheter with a leg bag.
Correct Answer: C
Rationale: The Credé maneuver, which involves applying manual pressure to the bladder, can facilitate voiding in clients with a flaccid bladder due to a spinal cord injury at T3. Indwelling catheters increase the risk of urinary tract infections and are generally avoided. Stroking the medial thigh is used for upper motor neuron issues, not flaccid bladders. A Texas catheter is unsuitable as the client may be unaware of a full bladder and unable to control voiding.
You may also like to solve these questions
A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture?
- A. Apply shoes to improve foot support.
- B. Perform weight-bearing activities.
- C. Increase calcium-rich foods in the diet.
- D. Use pressure-relieving devices.
Correct Answer: B
Rationale: Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, decreasing the risk of fractures in clients with decreased mobility. While increasing calcium-rich foods is beneficial for bone health, it alone will not sufficiently reduce fracture risk. Foot support and pressure-relieving devices help with mobility and skin integrity but do not directly address bone strength or fracture prevention.
A rehabilitation nurse is caring for an older adult client who states, 'I tire easily.' How should the nurse respond? (Select all that apply.)
- A. Make a schedule for completing major tasks in the morning.
- B. Use a cart to push your belongings instead of carrying them.
- C. Your family should hire someone who can assist you with daily chores.
- D. Plan to gather all of the supplies needed for a chore prior to starting the activity.
- E. Try to break large activities into smaller parts to allow rest periods between activities.
Correct Answer: B,D,E
Rationale: Using a cart reduces energy expenditure compared to carrying items. Gathering supplies before starting a chore minimizes unnecessary steps. Breaking large activities into smaller parts allows rest periods, helping manage fatigue. Scheduling major tasks in the morning is a good strategy but not listed as an option. Hiring assistance is not ideal as it does not promote independence.
A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- A. Place pillows under the client's heels.
- B. Have the client do wheelchair push-ups.
- C. Perform wound care as prescribed.
- D. Massage the client's calves and feet with lotion.
Correct Answer: B
Rationale: Clients who are wheelchair-bound should perform wheelchair push-ups for at least 10 seconds every hour to relieve pressure on weight-bearing areas, reducing the risk of skin breakdown. Pillows under the heels may increase pressure, wound care treats existing ulcers, and massaging the calves in clients with decreased mobility risks embolization.
A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
- A. Use analgesic before and after activity, even if you are not experiencing pain.
- B. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
- C. Use physical therapy before and after activity.
- D. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Correct Answer: B
Rationale: Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must instruct the client to report symptoms such as shortness of breath, chest pain, or fatigue, which indicate that the heart is not receiving adequate oxygen during activity. Using analgesics prophylactically is not necessary unless prescribed. Physical therapy is a structured program, not something used before and after activity. Rescheduling therapy due to knee pain may delay recovery, and pain should be managed appropriately instead.