A nurse is assisting in the care of a light-skinned client who has an ileostomy
The nurse is reviewing the client's medical record.
Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.
Day 1:
Abdomen soft, nondistended.
Ileostomy present. Stoma is red.
Stoma draining brown liquid stool.
Client will not look at stoma
Client states they are not interested in learning about stoma care.
Day 2:
Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
Stoma with small amount of bleeding noted during cleaning.
Abdomen soft, nondistended.
Ileostomy present. Stoma is red.
Stoma draining brown liquid stool.
Client will not look at stoma
Client states they are not interested in learning about stoma care.
Ileostomy pouch changed.
Stoma with small amount of bleeding noted during cleaning.
Skin surrounding stoma is reddened and has small open areas.
The Correct Answer is ["D","E","H"]
ANSWERED:
Day 1:
- Abdomen soft, nondistended.
- Ileostomy present. Stoma is red.
- Stoma draining brown liquid stool.
- Client will not look at stoma
- Client states they are not interested in learning about stoma care.
Day 2:
- Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
- Stoma with small amount of bleeding noted during cleaning.
Rationale:
Findings requiring intervention
Client will not look at stoma: This indicates potential emotional distress, denial, or difficulty adjusting to the ileostomy. The nurse should address these concerns by providing emotional support and encouraging gradual acceptance of the stoma through education and therapeutic communication.
Client states they are not interested in learning about stoma care: A lack of interest in learning stoma care poses a barrier to self-care and independence. The nurse should explore the client’s feelings, provide gentle encouragement, and offer step-by-step guidance to build their confidence.
Skin surrounding stoma reddened and has small open areas: Redness and open areas suggest irritation or breakdown of peristomal skin, likely due to improper pouch application or leakage. The nurse should assess the fit of the ileostomy pouch, recommend barrier creams, and consult a wound care specialist if needed.
Findings not requiring intervention
Abdomen soft, nondistended: This finding is normal and does not indicate any issues requiring intervention.
Stoma is red: A healthy stoma is typically moist, red, and similar in appearance to the inside of the mouth. This finding is expected.
Stoma draining brown liquid stool: Brown liquid stool is a normal output for an ileostomy and does not require intervention.
Stoma with small amount of bleeding noted during cleaning: Minimal bleeding from the stoma is common during cleaning or manipulation, especially early postoperatively. This is generally not a concern unless the bleeding is excessive or persistent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who is postoperative and has a urine output of 50 ml for the past 3 hr: This is concerning, but the low potassium level represents a more immediate threat to the client's health.
B. A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning: While a fever should be addressed, it is not as urgent as the potassium imbalance.
C. A client who is complaining of nausea and has a heart rate of 100 bpm: This heart rate is within a normal range for many clients, and nausea alone does not warrant immediate intervention.
D. A client who has a serum potassium level of 2.9 mEq/L: Hypokalemia is a critical electrolyte imbalance that requires immediate attention to prevent life-threatening complications, such as cardiac arrhythmias.
Correct Answer is C
Explanation
A. Burn injuries are physical stressors.
B. Hypothermia is a physical stressor.
C. Financial difficulties are a psychological stressor, as they can cause emotional distress and anxiety.
D. A wrist fracture is a physical stressor.
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