A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Intestinal obstruction

Folate deficiency

Malabsorption of fat

Fluid and electrolyte imbalance

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.

Choice B Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.

Choice C Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.

Choice D Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.

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Correct Answer is D

Explanation

Choice A Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves.

Choice B Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases.

Choice C Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection.

Choice D Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.

A. A blister-like pustule on the face that oozes clear fluid B. A dark brown lesion that is flat C. A small scaly, dry lesion on the elbow D. Location on the top of the head where exposed frequently to sunlight

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a blister-like pustule on the face that oozes clear fluid may indicate impetigo, which is a bacterial skin infection, not basal cell carcinoma. Basal cell carcinoma is a type of skin cancer that arises from the basal layer of the epidermis, which is the outermost layer of the skin. Basal cell carcinoma lesions are usually not blistered or pustular, but rather smooth, shiny, or waxy.

Choice B Reason: This is incorrect because a dark brown lesion that is flat may indicate a mole, which is a benign growth of melanocytes, which are cells that produce pigment, not basal cell carcinoma. Basal cell carcinoma lesions are usually not dark brown or flat, but rather flesh-colored, pink, or red, and may have a raised or indented center.

Choice C Reason: This is correct because a small scaly, dry lesion on the elbow may indicate basal cell carcinoma. Basal cell carcinoma lesions are often small, scaly, and dry, and may bleed or crust over. They can occur anywhere on the body, but are more common on areas that are exposed to the sun, such as the face, neck, arms, or legs.

Choice D Reason: This is incorrect because location on the top of the head where exposed frequently to sunlight may indicate squamous cell carcinoma, which is another type of skin cancer that arises from the squamous layer of the epidermis, not basal cell carcinoma. Squamous cell carcinoma lesions are usually rough, scaly, or crusted, and may have a firm or hard texture. They can also occur anywhere on the body, but are more common on areas that are exposed to the sun.

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A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?

Correct Answer is D

Explanation

When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?