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
The correct answer ischoice C.
Choice A rationale:
A lead level of 10 mcg/dL is above the CDC’s reference value of 3.5 mcg/dL and would require more immediate follow-up and intervention, not just rescreening in one year.
Choice B rationale:
A lead level of 18 mcg/dL is significantly elevated and would necessitate immediate medical intervention and frequent monitoring, rather than waiting a year for rescreening.
Choice C rationale:
A lead level of 4 mcg/dL is slightly above the CDC’s reference value of 3.5 mcg/dL.While it is concerning, it may be appropriate to rescreen in one year if no other risk factors are present.
Choice D rationale:
A lead level of 44 mcg/dL is dangerously high and requires urgent medical treatment and frequent follow-up, not just rescreening in one year.
Correct Answer is B
Explanation
The nurse should suspect candidiasis, also known as oral thrush.
Candidiasis is a fungal infection that can occur in the mouth and is characterized by the presence of a white, milky plaque that does not come off with rubbing.
The child’s use of antibiotics, immunosuppressants, and corticosteroids can increase the risk of developing candidiasis.
Choice A is incorrect because dermatitis is an inflammation of the skin and
would not present as a white plaque in the mouth.
Choice C is incorrect because herpes simplex typically presents as painful blisters or sores in the mouth.
Choice D is incorrect because squamous cell carcinoma typically presents as a firm, painless growth, or ulcer in the mouth.
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