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 ["A","C","D"]
Explanation
Choice A rationale:
Donning sterile gloves before inserting the indwelling urinary catheter is a standard practice in healthcare to prevent infection. The urinary tract is normally sterile, and the use of sterile gloves helps maintain this sterility during the catheter insertion process. Choice B rationale:
Oil-based lubricants should not be used with indwelling urinary catheters. These lubricants can damage the catheter material and increase the risk of infection. Instead, water-soluble lubricants are recommended as they do not damage the catheter and can reduce patient discomfort during the insertion process.
Choice C rationale:
Testing the balloon on the indwelling urinary catheter before insertion is a critical step. This is done to ensure that the balloon inflates and deflates properly. If the balloon does not function correctly, it could cause discomfort or injury to the patient during insertion and could fail to keep the catheter in place once inserted.
Choice D rationale:
Cleaning the patient’s urinary meatus with one cotton swab is a part of the standard procedure before inserting an indwelling urinary catheter. This step is taken to remove any bacteria present at the site of insertion, thereby reducing the risk of introducing bacteria into the bladder during the catheter insertion.
Correct Answer is A
Explanation
Choice A rationale:
Muscle twitching is a symptom of oxygen toxicity. Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen (O2) at increased partial pressures. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs, and eyes. Central nervous system symptoms can include muscle twitching.
Choice B rationale:
Redness of the face is not typically associated with oxygen toxicity. Oxygen toxicity primarily affects the central nervous system, lungs, and eyes. It does not typically cause redness of the face.
Choice C rationale:
Swelling around the eyes is not a common symptom of oxygen toxicity. The primary effects of oxygen toxicity are seen in the central nervous system, lungs, and eyes. However, this does not typically manifest as swelling around the eyes.
Choice D rationale:
A metallic taste in the mouth is not a known symptom of oxygen toxicity. Oxygen toxicity is a condition that results from the harmful effects of breathing molecular oxygen (O2) at increased partial pressures. It primarily affects the central nervous system, lungs, and eyes, but a metallic taste in the mouth is not a recognized symptom.
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