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:
Collecting urine from the catheter’s port is not the correct procedure when collecting a urine specimen for culture and sensitivity through straight catheterization. The port is not a sterile environment and could contaminate the specimen, leading to inaccurate results.
Choice B rationale:
Using a sterile specimen container is the correct procedure. This ensures that the specimen is not contaminated by any external bacteria or substances, which could affect the results of the culture and sensitivity test. The container must be sterile to prevent the growth of microbes that are not present in the urine sample. This helps to ensure that the results of the culture are accurate and reflect the microbes present in the urine, not those introduced during collection.
Choice C rationale:
Inflating the balloon with sterile water is not a step in this procedure. The balloon is part of an indwelling catheter, not a straight catheter. An indwelling catheter remains in the bladder for a longer period, and the balloon is inflated to keep it in place. A straight catheter is used for a single voiding or to obtain a sterile urine specimen.
Choice D rationale:
Instructing the patient to clean from front to back with an antiseptic solution is not a step in this procedure. While maintaining cleanliness is important, this specific instruction is more relevant to a clean-catch midstream urine specimen, not a specimen collected through straight catheterization.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.
Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.
Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.
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