A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

Half-strength infant formula

Sterile water

Oral electrolyte solution

Half-strength orange juice

Answer and Explanation

The Correct Answer is C

A. Half-strength infant formula: Infant formula, even if diluted, may not be appropriate immediately after a repair of intussusception. It may be too heavy for the infant's digestive system, potentially leading to complications. Clear fluids are usually preferred initially.

B. Sterile water: Sterile water is not typically recommended for oral intake in infants after a repair of intussusception. It lacks essential electrolytes needed to maintain proper hydration and electrolyte balance.

C. Oral electrolyte solution: Oral electrolyte solutions, such as Pedialyte, are often recommended for infants after a repair of intussusception. These solutions contain balanced electrolytes and fluids, which help prevent dehydration and restore electrolyte balance.

D. Half-strength orange juice: Orange juice, even if diluted, is not typically recommended immediately after a repair of intussusception. It may be too acidic and may cause gastrointestinal discomfort or irritation in the infant. Clear fluids are preferred initially to allow the gastrointestinal tract to rest and recover.

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Correct Answer is D

Explanation

A. Repression: Repression involves unconsciously pushing unwanted thoughts, memories, or feelings out of conscious awareness. It involves burying distressing emotions or memories deep in the unconscious mind to avoid dealing with them consciously. In this scenario, the client's behavior does not suggest the repression of any specific thoughts or memories but rather a coping mechanism related to their current stress and anxiety.

B. Introjection: Introjection occurs when an individual internalizes the values, beliefs, or attitudes of others as if they were their own. It involves incorporating external standards or influences into one's own identity. While introjection may contribute to the client's behavior indirectly by influencing their beliefs about needing external support, the primary defense mechanism at play in this scenario is regression.

C. Dissociation: Dissociation involves a disruption in the integration of consciousness, memory, identity, or perception of the environment. It often manifests as a detachment from reality or a sense of being disconnected from oneself or the surrounding environment. While dissociation may occur in response to severe stress or trauma, it typically involves more extreme symptoms than those described by the client in this scenario.

D. Regression: Regression involves reverting to earlier, less mature behaviors or stages of development in response to stress or anxiety. It reflects a retreat to a more comfortable or familiar state in an attempt to cope with overwhelming emotions or situations. In this scenario, the client's statement about needing someone to take care of them suggests a desire to return to a state of dependency, which is characteristic of regression as a defense mechanism.

A. "I use a suppository every night to have a bowel movement." B. "I only need to catheterize myself twice every day." C. "I carry a water bottle with me because I drink a lot of water." D. "I do wheelchair exercises while watching TV."

Correct Answer is B

Explanation

A. "I use a suppository every night to have a bowel movement": This statement indicates an appropriate understanding of managing bowel function, as regular bowel movements are essential for individuals with spinal cord injury to prevent complications such as constipation.

B. "I only need to catheterize myself twice every day": Individuals with spinal cord injury and paralysis often require intermittent catheterization at regular intervals to empty their bladders completely and prevent urinary retention. Twice-daily catheterization may not be sufficient for adequate bladder management and could lead to urinary complications such as urinary tract infections or bladder overdistention. The client may need further teaching to understand the importance of more frequent catheterization.

C. "I carry a water bottle with me because I drink a lot of water": Staying hydrated is crucial for individuals with spinal cord injury to prevent urinary tract infections and maintain overall health. Carrying a water bottle indicates an appropriate understanding of the importance of hydration.

D. "I do wheelchair exercises while watching TV": Engaging in wheelchair exercises is beneficial for maintaining strength, mobility, and overall health for individuals with spinal cord injury. This statement demonstrates an understanding of the importance of physical activity and exercise in the client's daily routine.

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A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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