A nurse is developing a plan of care for a client who has a new ileal conduit. Which of the following should the nurse include as risks for the client? (Select all that apply.)
Anxiety
Impaired skin integrity
Infection
Fluid volume deficit
Disturbed body image
Correct Answer : B,C,D,E
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A history of high blood pressure is a risk factor for chronic kidney disease but not specifically for acute glomerulonephritis. Acute glomerulonephritis is more commonly associated with infections.
Choice B rationale
A recent sore throat and fever, especially if caused by a streptococcal infection, can lead to post-streptococcal glomerulonephritis. This is a well-documented cause of acute glomerulonephritis, making it the correct answer.
Choice C rationale
While bladder infections can lead to urinary tract infections, they are not typically associated with acute glomerulonephritis. This condition is more commonly related to infections that can cause a systemic immune response.
Choice D rationale
A history of kidney stones is associated with chronic kidney issues and can lead to infections, but it is not a direct cause of acute glomerulonephritis. This condition is usually caused by an immune response to an infection elsewhere in the body.
Correct Answer is C
Explanation
Choice A rationale
Hemorrhage refers to bleeding, which can be a serious complication of peptic ulcer disease but does not lead to the spilling of gastric contents into the peritoneal cavity.
Choice B rationale
Dumping syndrome is a condition where food moves too quickly from the stomach to the small intestine, which can cause symptoms like nausea and abdominal pain, but it does not involve the leakage of gastric contents into the peritoneal cavity.
Choice C rationale
Perforation is the correct answer because it describes a hole forming in the wall of the stomach or duodenum, allowing gastric contents to spill into the peritoneal cavity, leading to peritonitis, which is a severe and life-threatening condition.
Choice D rationale
Gastric outlet obstruction is a blockage at the end of the stomach that prevents contents from entering the small intestine, which can cause vomiting and abdominal pain, but it does not result in the leakage of gastric contents into the peritoneal cavity.
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