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 C
Explanation
Infants with spina bifida are at an increased risk of developing a latex allergy
due to repeated exposure to latex products during medical procedures.
Providing a latex-free environment can help prevent the development of an allergy.
Choice A is not correct because limiting visitors to immediate family members is not necessary for the care of an infant undergoing surgical closure of the myelomeningocele sac.
Choice B is not correct because maintaining the infant in the supine position is not necessary for this procedure.
Choice D is not correct because initiating contact precautions is not necessary for this procedure.
Correct Answer is D
Explanation
a.Talcum powder is not recommended for use with infants because it can be inhaled, potentially causing respiratory problems. Instead, a barrier cream or ointment (such as zinc oxide or petroleum jelly) should be used to protect the skin from moisture and irritants.
b.While cloth diapers can be less irritating than some disposable diapers, they may not be as effective at keeping the skin dry. The priority is to keep the area dry and clean, regardless of the type of diaper used. Super-absorbent disposable diapers are often recommended because they can help keep the skin dry.
c.Exposing the skin to hot air can cause burns and further irritation. Instead, allowing the skin to air dry naturally (without the use of hot air) during diaper changes can be beneficial.
d.A moisturizer creates a barrier between the skin and irritants like urine and stool.Wiping with a moisturizer can minimize friction during cleaning, which can be uncomfortable for the baby and further irritate the skin.Some moisturizers can help soothe and hydrate the inflamed skin, promoting healing.
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