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 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.
Correct Answer is D
Explanation
a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.
d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
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