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
The correct answer is choice D: Pediculosis capitis.
Choice D rationale: Pediculosis capitis is an infestation of head lice, which causes symptoms such as white flakes that do not brush off the hair easily and a rash on the back of the neck. These symptoms are due to the lice feeding on the scalp and laying eggs (nits), which can cause itching and irritation.
Choice A rationale: Folliculitis is an inflammation of the hair follicles, typically caused by bacterial or fungal infections. While it can cause a rash, it is not characterized by white flakes in the hair.
Choice B rationale: Tinea capitis, also known as ringworm of the scalp, is a fungal infection that causes scaly, itchy patches on the scalp. It may lead to hair loss in the affected areas, but it does not typically cause white flakes that do not brush off the hair.
Choice C rationale: Impetigo contagiosa is a highly contagious bacterial skin infection that causes blisters or sores on the skin. It does not involve white flakes in the hair and primarily affects exposed skin rather than the scalp.
Correct Answer is D
Explanation
When determining that Bryant's traction is appropriately assembled, the nurse should observe that the buttocks is elevated slightly off of the bed.
In Bryant traction, both of the patient’s limbs are suspended in the air vertically at a ninety-degree angle from the hips and knees slightly flexed.
Choice A is incorrect because a padded sling is not used under the knee of the affected leg in Bryant traction.
Choice B is incorrect because skin straps are not used to maintain the leg in an
extended position in Bryant traction.
Choice C is incorrect because weights are not attached to a pin that is inserted into the femur in Bryant traction.
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