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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Allowing an infant with a cast for DDH to stand in the crib could place undue stress on the hips and may not be safe, depending on the type of cast and the stability of the condition. Most spica casts will not allow the child to stand, walk or bear any weight.
B.Providing a small electronic toy can help stimulate the infant's sensory and cognitive development. At 10 months old, infants are curious and responsive to interactive toys that can engage their senses and promote fine motor skills and cognitive development.
C.Tie colorful latex balloons to the side of the crib.: While colorful objects can be visually stimulating, latex balloons pose a choking hazard if they burst or are chewed on by the infant. It is safer to use other forms of visual stimulation, such as colorful toys or mobiles.
D.Change the infant's diaper as soon as soiling occurs.: While it is essential to keep the infant clean and dry to prevent skin irritation and infection, this action, although necessary, does not directly promote growth and development. It is a basic care measure rather than a developmental strategy.
Correct Answer is D
Explanation
A. Semi-Fowler's. While this position can help with drainage, it is generally not the first choice immediately after VP shunt surgery.
B. Prone.This position is generally not recommended as it can cause discomfort and increase intracranial pressure.
C. Trendelenburg. This position is contraindicated as it can significantly increase intracranial pressure.
D. on the unoperated side. This position helps prevent pressure on the operative site and facilitates drainage of cerebrospinal fluid. It also reduces the risk of complications associated with increased intracranial pressure.
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