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
Activated charcoal should be given as soon as possible to help absorb the acetylsalicylic acid in the gastrointestinal tract.
Choice A is not an answer because N-acetylcysteine is used to treat acetaminophen overdose, not acetylsalicylic acid overdose.
Choice B is not an answer because chelation therapy with deferoxamine is used to treat iron poisoning, not acetylsalicylic acid overdose.
Choice D is not an answer because inducing vomiting with syrup of ipecac is no longer recommended for the treatment of poisoning due to the potential for harm and lack of evidence of benefit.
Correct Answer is D
Explanation
This is the recommended technique for chest compressions on an infant, as it provides adequate blood flow without causing injury12.
Choice A.
Deliver compressions just above the nipple line is incorrect, as this is not the correct location for chest compressions on an infant.
The correct location is below the nipple line, at the center of the chest.
Choice B.
Deliver compressions with the heel of one hand is incorrect, as this is the technique for chest compressions on a child, not an infant. For an infant, two fingers are used instead of one hand13.
Choice C.
Deliver compressions at a depth of 5 cm (2 in) is incorrect, as this is too deep for an infant’s chest.
The correct depth for an infant is about 4 cm (1.5 in) or 1/3 the depth of the
chest12.
Therefore, choice D is the best answer.
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