A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

“I only need to catheterize myself twice every day.”.

“I use a suppository every night to have a bowel movement.”.

“I do wheelchair exercises while watching TV.”.

“I carry a water bottle with me because I drink a lot of water.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The statement “I only need to catheterize myself twice every day” should alert the nurse to the need for further education. Individuals with spina bifida who are paralyzed from the waist down often need to perform clean intermittent catheterization (CIC) every 3-4 hours to empty the bladder and prevent urinary tract infections.
Choice B rationale
Using a suppository every night to have a bowel movement is a common practice among individuals with spina bifida. Due to the paralysis, they often have difficulty with bowel movements and may use suppositories or other methods to stimulate bowel movements.
Choice C rationale
Doing wheelchair exercises while watching TV is a good practice for individuals with spina bifida. Regular physical activity can help improve strength, flexibility, and overall health.
Choice D rationale
Carrying a water bottle and drinking a lot of water is a good practice for individuals with spina bifida. Adequate hydration can help prevent urinary tract infections and kidney stones, which are common complications in individuals who perform CIC78910.

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Correct Answer is C

Explanation

Choice C rationale
The apex of the heart is the most appropriate site to assess an infant’s heart rate. In infants, the apical pulse provides the most accurate assessment of heart rate. The apical pulse is located at the fifth intercostal space at the midclavicular line.
Choice A rationale
The carotid artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
Choice B rationale
The brachial artery can be used to assess an infant’s heart rate, but it is typically used for blood pressure measurements rather than heart rate assessments.
Choice D rationale
The radial artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.

A. Intravenous fluids (IVF) at maintenance rate B. Meperidine IV for pain C. Ice packs to the affected area for 15 min on/15 min off D. Oxygen 2 L/min via nasal cannula

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.

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A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure an infant’s vital signs. Which of the following sites should the nurse use to assess the heart rate?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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