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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.
B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.
C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.
D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.
Correct Answer is C
Explanation
A. Blood pressure 108/62 mm Hg: Lisinopril is an antihypertensive, and a systolic BP above 90 mm Hg is typically not considered an adverse effect. Hypotension can occur but is more concerning if it results in symptoms such as dizziness or syncope.
B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L): Lisinopril can cause hyperkalemia, but a potassium level of 3.5 mEq/L is within the normal range. Monitoring potassium levels is essential, but this finding does not indicate an adverse effect.
C. Frequent, nonproductive cough: A dry, persistent cough is a common adverse effect of lisinopril due to the accumulation of bradykinin. It often does not resolve until the medication is discontinued or switched to an alternative, such as an angiotensin receptor blocker (ARB).
D. Frequent, painless urination: Lisinopril does not typically cause increased urination. While it affects renal function, it is more likely to lead to hyperkalemia or reduced glomerular filtration rate in susceptible individuals.
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