A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?
I do my wheelchair exercises sitting in my chair.
I use a suppository every night to have a bowel movement.
I need to catheterize myself twice a day.
I carry a water bottle with me because I drink a lot of water.
The Correct Answer is C
Choice A rationale:
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
Choice B rationale:
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:
The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
Choice D rationale:
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis.
While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
Choice B rationale:
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins.
BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
Choice C rationale:
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals.
It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
Choice D rationale:
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube.
A high ESR can indicate inflammation in the body.
ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Choice E rationale:
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection.
A high WBC count can indicate an infection or inflammation.
WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today