A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?
"I do wheelchair exercises while watching TV.".
"I carry a water bottle with me because I drink a lot of water.".
"I use a suppository every night to have a bowel movement.".
"I only need to catheterize myself twice every day.".
The Correct Answer is D
Individuals with spina bifida who are paralyzed from the waist down may have difficulty emptying their bladder completely and may need to perform intermittent catheterization.
The frequency of catheterization can vary depending on the individual’s needs, but it is typically performed every 3-6 hours or 4-6 times per day.
Choice A, “I do wheelchair exercises while watching TV,” is a positive statement because exercise is important for overall health and well-being.
Choice B, “I carry a water bottle with me because I drink a lot of water,” is also a positive statement because staying hydrated is important for overall health.
Choice C, “I use a suppository every night to have a bowel movement,” is not necessarily an indication for further teaching because some individuals with spinal bifida may need to use bowel management techniques such as suppositories to help regulate bowel movements.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement helps the child understand that they are not to blame for the abuse and can help reduce feelings of guilt or shame.
Choice A is not an answer because it can create more confusion and fear in the child.
Choice B is not an answer because discussing the abuse with the family may not be safe or appropriate.
Choice D is not an answer because it is important for the nurse to report the abuse to the appropriate authorities to ensure the child’s safety.
Correct Answer is B
Explanation
This is an important measure to prevent the spreading of impetigo to others and to other parts of the body, as the bacteria can survive on clothing and other objects12.
Choice A.
Keeping the child on droplet precautions at home is incorrect, as impetigo is not spread by respiratory droplets, but by direct contact with the sores or contaminated items.
Choice C.
Immunizing household contacts for the disease is incorrect, as there is no vaccine for impetigo, which is caused by different types of bacteria.
Choice D.
Giving the child a chlorine bath twice daily is incorrect, as chlorine can irritate the skin and worsen impetigo.
The recommended treatment is to wash the sores with soap and water and
apply antibiotic ointment or cream23.
Therefore, choice B is the best answer to this question.
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