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","D","E"]
Explanation
The correct answers are C, D, and E.
Choice A rationale: Intact epidermis would not be expected with a partial-thickness burn as the burn extends into the dermis.
Choice B rationale: A dry surface is not characteristic of partial-thickness burns, which typically have a moist surface.
Choice C rationale: Partial-thickness burns are sensitive to touch due to the damage to nerve endings in the dermis.
Choice D rationale: Wound blanches with pressure because the blood vessels are damaged, allowing blanching on pressure.
Choice E rationale: Blisters are a common feature of partial-thickness burns, as the damage to the dermis causes fluid to accumulate.
Correct Answer is A
Explanation
Chronic glomerulonephritis is a condition that causes inflammation of the glomeruli, which are tiny filtering units in the kidneys.
This can lead to poor kidney function and an increase in waste products in the bloodstream.
Blood urea nitrogen (BUN) is a waste product that is normally filtered by the kidneys and excreted in urine.
A BUN level of 50 mg/dL is higher than the normal range, indicating poor kidney function.
Choice B is incorrect because a serum phosphorus level of 4.0 mg/dL is within
the normal range for adults.
Choice C is incorrect because a serum potassium level of.8 mEq/L is within the normal range for adults.
Choice D is incorrect because proteinuria (the presence of protein in urine) is a
common finding in glomerulonephritis.
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