A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which of the following client statements would require further teaching?
1. "I need to perform self-catheterization three times daily.".
2. "I know I cannot look to see if my bladder is full.".
3. "I need to avoid bladder distention.".
4. "I'll drink adequate amounts of liquids.".
1
Rationale 1: "I need to perform self-catheterization three times daily," would indicate the client needs further teaching since emptying the bladder only 3 times in 24 hours is insufficient. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention by performing self-catheterization before this happens, most likely every 3 to 4 hrs.
Rationale 2: "I know I cannot look to see if my bladder is full," would indicate the client understands his condition and care. By the time the client can see his abdomen expand or have a sense of bladder fullness—if able to have this sensation—the bladder would be overdistended and dysreflexia could occur. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention.
Rationale 3: "I need to avoid bladder distention," indicates that the client understands his condition and care. Bladder distention can lead to dysreflexia. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis.
Rationale 4: "I'll drink adequate amounts of liquids," indicates that the client understands his condition and care. Adequate fluid intake is appropriate for the urinary system to function properly and to maintain homeostasis.
You might also like to view...
Which populations are at the highest risks of contracting HIV? (Select all that apply.)
a. Health care workers who mishandle in-fected sharps b. Breastfed infants of HIV-infected mothers c. Persons sharing living quarters with an HIV-infected person d. Heterosexual partners of an HIV-infected person e. Newborns of an HIV-infected mother
A patient experienced a period of momentary confusion, dizziness, and slurred speech, but recovered in 2 hours. The most helpful assessment in the diagnosis of this episode would be:
1. patient complaint of nausea. 2. blood pressure of 140/90. 3. patient complaint of headache. 4. auscultation of a bruit over the carotid.
After surgical debridement of diseased bone, a client with acute osteomyelitis asks how long antibiotics will be administered. The nurse should respond that the antibiotic protocol will be
a. oral antibiotics for 2-4 weeks. b. oral antibiotics for 4-8 weeks. c. parenteral for 4-8 weeks, then oral for 4-8 weeks. d. parenteral for 4-8 weeks, then oral for 1 year.
The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks gestation. The most appropriate term for this is:
A) Preterm birth B) Term birth C) Small for gestational age infant D) Large for gestational age infant