A nurse is preparing discharge teaching for a client who has Crohn's disease and a new ileostomy. Which of the following community resources should the nurse include in the teaching?
Hospice care services
Long-term care facility
Rehabilitation center
Visiting nurse services
The Correct Answer is D
A. Hospice care services: Hospice care is designed for clients with terminal illnesses who require end-of-life care. Crohn’s disease and an ileostomy do not indicate a terminal condition, making hospice services inappropriate for this client.
B. Long-term care facility: Long-term care facilities are for clients who need continuous medical or personal care and are unable to live independently. Most clients with an ileostomy can manage their care at home with proper education and support, making this resource unnecessary.
C. Rehabilitation center: Rehabilitation centers are primarily for clients recovering from major injuries, strokes, or surgeries that impair mobility or function. While an ileostomy requires adjustment, it does not typically necessitate inpatient rehabilitation.
D. Visiting nurse services: Home health nurses provide essential support for clients with a new ileostomy by assisting with ostomy care, monitoring for complications, and reinforcing self-care education. This service helps facilitate a smoother transition to independent ostomy management.
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Related Questions
Correct Answer is B
Explanation
A. Graham crackers: Hard, crunchy foods can trigger pain by irritating the trigeminal nerve, making them unsuitable for clients with trigeminal neuralgia. Soft, easy-to-swallow foods are preferred.
B. Vanilla pudding: Soft, smooth-textured foods are recommended to minimize irritation of the trigeminal nerve. Vanilla pudding requires minimal chewing, reducing the risk of triggering pain.
C. Ice cream: Extremely cold foods can act as a trigeminal nerve irritant and may provoke pain episodes. Lukewarm or room-temperature foods are preferable.
D. Vegetable soup: Although liquid-based, vegetable soup often contains solid pieces that require chewing, which can increase the risk of triggering pain. Blended or pureed soups are a better option.
Correct Answer is B
Explanation
A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.
B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.
C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.
D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.
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