A nurse is caring for 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.
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 stomas reddened and has small open areas
- stoma with small amount of bleeding noted during cleaning.
Client will not look at stoma
Client states they are not interested in learning about stoma care
Skin surrounding stomas reddened and has small open areas
Ileostomy pouch changed.
stoma with small amount of bleeding noted during cleaning.
Abdomen soft, nondistended
Ileostomy present. Stoma is red.
The Correct Answer is ["A","B","C"]
The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.
A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.
Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A urine specific gravity of 1.015 is within the normal range, so it is not indicative of dehydration.
B. Cloudy urine may indicate infection but is not a hallmark sign of dehydration.
C. A urine osmolality of 200 mOsm/kg is low and more consistent with overhydration rather than dehydration.
D. Dark-colored urine is a common sign of dehydration, as concentrated urine results from reduced fluid intake.
Correct Answer is D
Explanation
A. Taking the client to the toilet immediately before a meal does not correlate with the natural timing of defecation.
B. Abdominal cramping may indicate constipation or other issues, but waiting for cramping is not part of bowel training.
C. Taking the client to the toilet every 2 hours may not align with the client’s natural bowel habits.
D. The goal of bowel training is to help the client recognize and respond to the urge to defecate, promoting regular bowel habits and reducing incontinence.
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