Nokea
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
- A. Stroke the inner aspect of your thigh to initiate voiding.
- B. Implement digital anal stimulation when your bladder is full.
- C. Tighten your abdominal muscles to stimulate urine flow.
- D. Use a catheter to empty your bladder completely.
Correct Answer: C
Rationale: In clients with lower motor neuron injuries, performing a Valsalva maneuver by tightening abdominal muscles can stimulate urine flow. The other options are not effective for achieving bladder control in this context.
You may also like to solve these questions
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 assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
- A. Pain at the surgical site.
- B. Numbness in the lower extremities.
- C. Difficulty breathing.
- D. Weak pedal pulses.
Correct Answer: C
Rationale: Difficulty breathing could indicate a compromised airway, possibly due to swelling, which is a critical postoperative complication requiring immediate attention. Pain, numbness, and weak pulses are important but not as urgent as airway issues.
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Surgical discomfort.
- B. Redness and itching at the incision site.
- C. Incisional bulging.
- D. Clear drainage on the dressing.
- E. Sudden and severe headache.
Correct Answer: C,D,E
Rationale: Incisional bulging, clear drainage (possible CSF leak), and severe headache are emergencies post-laminectomy. Surgical discomfort and redness/itching are normal and not urgent.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
- A. Assess level of consciousness.
- B. Obtain vital signs.
- C. Administer oxygen therapy.
- D. Evaluate respiratory status.
Correct Answer: D
Rationale: The first priority for a client with a cervical spinal cord injury is to assess respiratory status and airway patency, as these injuries can compromise breathing. Other assessments follow after ensuring airway and breathing are stable.
A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask?
- A. Are you taking a nonsteroidal anti-inflammatory drug?
- B. Do you have a history of psychiatric disorders?
- C. Do you have difficulty swallowing medications?
- D. Do you smoke cigarettes or any illegal drugs?
Correct Answer: B
Rationale: Ziconotide can cause psychiatric side effects, so assessing for a history of psychiatric disorders is crucial. The other questions are less relevant to ziconotide's safety profile.