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 : A,B,C,E
Choice A reason: A new ileal conduit is a permanent life change that requires the client to learn complex self-care skills. The uncertainty regarding stoma management, fear of appliance leakage in public, and the lifestyle adjustments required often lead to significant anxiety. The nurse must address these psychological stressors during the initial postoperative period to promote successful adaptation.
Choice B reason: The continuous drainage of urine from the stoma creates a high risk for peristomal skin breakdown. Urine is caustic to the skin, and moisture trapped under the skin barrier can lead to maceration, dermatitis, or fungal infections. Maintaining a secure, well-fitted appliance and assessing the skin frequently are essential nursing interventions for this risk.
Choice C reason: Surgical creation of an ileal conduit involves bowel resection and ureteral implantation, increasing the risk for peritonitis or wound infection. Furthermore, since the conduit is a direct pathway to the kidneys without a sphincter, the client is at lifelong risk for ascending urinary tract infections or pyelonephritis requiring vigilant monitoring.
Choice D reason: While postoperative patients require fluid monitoring, an ileal conduit does not typically cause a chronic fluid volume deficit. Unlike an ileostomy, where significant water and electrolytes are lost through liquid stool, the ileal conduit simply transports urine. Unless there is excessive surgical bleeding or unrelated dehydration, this is not a primary risk.
Choice E reason: The permanent diversion of urine to an external pouch on the abdomen significantly alters the client's physical appearance and "normal" elimination process. Concerns regarding sexual function, clothing choices, and the presence of a stoma frequently lead to a disturbed body image, necessitating supportive counseling and referral to an ostomy nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
Choice B rationale
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
Choice C rationale
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
Choice D rationale
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
Correct Answer is A
Explanation
Choice A rationale
In prerenal AKI, the kidneys are not receiving enough blood flow. As a result, they cannot filter potassium out of the blood efficiently, leading to hyperkalemia, which is an elevated level of potassium in the blood. This condition is dangerous because it can cause cardiac dysrhythmias and muscle weakness.
Choice B rationale
Hypernatremia, an elevated sodium level, is not typically associated with prerenal AKI. It is more commonly related to dehydration or an excessive intake of sodium, which are not direct consequences of prerenal AKI.
Choice C rationale
Hypercalcemia, an elevated calcium level, is also not a common finding in prerenal AKI. It is usually associated with other conditions such as hyperparathyroidism or malignancy.
Choice D rationale
Hypophosphatemia, a low level of phosphate in the blood, is not a typical result of prerenal AKI. It can occur due to malnutrition or malabsorption, but it is not directly caused by prerenal AKI.
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