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 A
Explanation
A.Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying positionis not recommended for a child with myelomeningocele. The preferred position isprone to avoid pressure on the sac and reduce the risk of rupture and infection.
C.Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D.Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
Correct Answer is C
Explanation
A bulging fontanel is a manifestation associated with a CNS infection in an 11- month-old infant.
A bulging fontanel can be a sign of increased intracranial pressure, which can
occur with meningitis or encephalitis, both of which are types of CNS infections.
Choice A is incorrect because oliguria, or decreased urine output, is not typically associated with a CNS infection.
Choice B is incorrect because jaundice, or yellowing of the skin and eyes, is not typically associated with a CNS infection.
Choice D is incorrect because a negative Brudzinski sign would indicate that there is no neck stiffness, which would be an unlikely finding in a CNS infection.
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