A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

"My stoma size will stay the same, even after it has healed."

"My stoma will drain liquid fluid continuously."

"I will change my pouch system every 2 weeks."

"I will ensure that my medications are enteric coated."

Answer and Explanation

The Correct Answer is B

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

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Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.

B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.

C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.

D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.

A. "You looked like you would be the most likely to talk back with me." B. "Let's go see what activities are going on outside." C. "Why shouldn't I talk to you? You looked lonely." D. "You're curious why I am interested in you and not the others?"

Correct Answer is D

Explanation

A. This response does not address the adolescent's underlying question and may come across as dismissive.

B. This response avoids addressing the adolescent's question and suggests changing the subject.

C. This response is somewhat confrontational and does not explore the adolescent's feelings or concerns.

D. This response acknowledges the adolescent's curiosity and opens the door for further discussion about why the nurse chose to engage with them. It invites the adolescent to explore their feelings and thoughts.

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A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

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Naxlex Comprehensive Predictor Exams

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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