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.”.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While fat-soluble vitamins are essential for overall health, they do not specifically prevent iron deficiency anemia. Iron deficiency anemia occurs when the body doesn’t have enough iron to produce hemoglobin, the part of red blood cells that gives them their red color and enables them to carry oxygen in the blood.
Choice B rationale
Limiting intake of high-protein foods is not a recommended method for preventing iron deficiency anemia. In fact, many high-protein foods, such as meat and eggs, are good sources of iron.
Choice C rationale
While fluoridated water can help prevent tooth decay, it does not prevent iron deficiency anemia. Iron deficiency anemia is prevented by consuming adequate amounts of iron, either from food sources or from supplements.
Choice D rationale
A diet that consists primarily of milk, particularly cow’s milk, can contribute to iron deficiency anemia. Cow’s milk is low in iron and can also decrease absorption of iron and irritate the lining of the intestine, causing small amounts of bleeding and the gradual loss of iron in the stool (poop)4.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.
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