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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Postpartum depression is characterized by severe mood swings, crying too much, difficulty bonding with the baby, withdrawing from family and friends, loss of appetite or eating much more than usual, inability to sleep or sleeping too much, overwhelming tiredness or loss of energy. While some of these symptoms overlap with the ones mentioned in the question, postpartum depression is usually more severe and lasts longer.
Choice B rationale
The letting-go phase is the final phase of maternal adjustment during which the mother moves forward from her existing role to take on a new one as a parent. This phase is characterized by reestablishment of relationships with others, resumption of sexual intimacy, resolution of physical symptoms, and attainment of a new normal. The symptoms mentioned in the question do not align with this phase.
Choice C rationale
Postpartum psychosis is a rare but serious mental health illness that can affect a woman soon after she has a baby. Symptoms can include hallucinations, delusions, a manic mood, a low mood, loss of inhibitions, restlessness, and severe confusion. The symptoms mentioned in the question do not align with this condition.
Choice D rationale
This is the correct answer. Postpartum fatigue is characterized by extreme tiredness that doesn’t get better with rest or sleep. This fatigue can make it difficult for the new mother to care for herself and her baby. The symptoms mentioned in the question - tearfulness, insomnia, lack of appetite, and a feeling of letdown - are all common symptoms of postpartum fatigue.
Correct Answer is D
Explanation
Choice A rationale
Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug (NSAID) that reduces fever, pain and inflammation. It is used to treat moderate to severe osteoarthritis, rheumatoid arthritis, gouty arthritis, or ankylosing spondylitis. It is not used to accelerate fetal lung maturity.
Choice B rationale
Nifedipine (Procardia) is a calcium channel blocker used to treat high blood pressure (hypertension) or chest pain (angina). It is not used to accelerate fetal lung maturity.
Choice C rationale
Calcium gluconate is used to prevent or to treat calcium deficiencies. It is not used to accelerate fetal lung maturity.
Choice D rationale
Betamethasone (Celestone) is a corticosteroid that is used to mature the lungs in fetuses at risk for preterm birth.
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