A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

“I only need to catheterize myself twice every day.”.

“I use a suppository every night to have a bowel movement.”.

“I do wheelchair exercises while watching TV.”.

“I carry a water bottle with me because I drink a lot of water.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The statement “I only need to catheterize myself twice every day” should alert the nurse to the need for further education. Individuals with spina bifida who are paralyzed from the waist down often need to perform clean intermittent catheterization (CIC) every 3-4 hours to empty the bladder and prevent urinary tract infections.
Choice B rationale
Using a suppository every night to have a bowel movement is a common practice among individuals with spina bifida. Due to the paralysis, they often have difficulty with bowel movements and may use suppositories or other methods to stimulate bowel movements.
Choice C rationale
Doing wheelchair exercises while watching TV is a good practice for individuals with spina bifida. Regular physical activity can help improve strength, flexibility, and overall health.
Choice D rationale
Carrying a water bottle and drinking a lot of water is a good practice for individuals with spina bifida. Adequate hydration can help prevent urinary tract infections and kidney stones, which are common complications in individuals who perform CIC78910.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.

A. Deep tendon reflexes of +1 B. Blood pressure 148/98 mm Hg C. 1+ pitting sacral edema D. 3+ protein in the urine .

Correct Answer is A

Explanation

Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage. One of the symptoms can be hyperreflexia, or overly active reflexes, not diminished reflexes.
Choice B rationale
Blood pressure of 148/98 mm Hg is consistent with preeclampsia, as one of the defining features of preeclampsia is high blood pressure.
Choice C rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, or swelling, is a common symptom of preeclampsia.
Choice D rationale
3+ protein in the urine is consistent with preeclampsia. One of the defining features of preeclampsia is the presence of excess protein in urine (proteinuria), which indicates kidney problems. Deep vein thrombosis Deep vein thrombosis Explore

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A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering magnesium sulfate IV to a client with severe preeclampsia for seizure prophylaxis. Which of the following are indications of magnesium sulfate toxicity? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is A

Explanation

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