A nurse is providing care for a young adult patient who has ulcerative colitis and is scheduled for an ileostomy surgery.
After a discussion with the healthcare provider, the patient expresses concern, “How will I ever be able to have a normal life after this?”
How should the nurse respond?
“Can you share how you think having the ileostomy will affect you?”
“Everyone worries about how they will manage their ileostomy at first.”.
“This will cure your disease so you don’t spend so much time in the hospital.”.
“Let’s discuss some strategies to help you adapt to life with an ileostomy.”. .
The Correct Answer is A
Choice A rationale
Asking the patient to share their concerns allows the nurse to understand the patient’s perspective and provide individualized care. It opens up a dialogue where the patient can express their fears and the nurse can provide reassurance and information.
Choice B rationale
While it’s true that many people worry about managing an ileostomy at first, this response does not address the patient’s specific concerns. It’s important to understand the patient’s individual fears and worries.
Choice C rationale
This response may be misleading. While an ileostomy can help manage the symptoms of ulcerative colitis, it does not cure the disease. It’s important to provide accurate information to the patient.
Choice D rationale
Discussing strategies to adapt to life with an ileostomy can be helpful, but it’s important to first understand the patient’s specific concerns. This response assumes what the patient needs without asking them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assuring the patient that the problem is temporary may not be accurate. Postoperative dysphagia could indicate a complication from the surgery, such as the stomach fundus being wrapped too tight around the esophagus, causing food obstruction. It’s important to not dismiss the patient’s concerns without proper assessment.
Choice B rationale
Cutting the food into small pieces might help the patient swallow easier, but it does not address the underlying issue. The patient’s difficulty in swallowing could be a sign of a serious problem that needs medical attention.
Choice C rationale
Reporting the observation to the healthcare provider (HCP) is the correct action. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction.
Choice D rationale
Offering the patient liquids instead might alleviate the symptom temporarily, but it does not solve the potential problem. The healthcare provider needs to be informed about the dysphagia to assess and treat the possible complication.
Correct Answer is C
Explanation
Choice A rationale
Absence of bowel sounds can be a normal finding post-operatively and is not necessarily a cause for concern.
Choice B rationale
A small amount of bloody drainage on the dressing is not uncommon after surgery and is not typically a cause for concern.
Choice C rationale
A rigid abdomen on palpation is a concerning finding after an appendectomy. It could indicate peritonitis, a serious infection of the abdominal cavity that can occur if the appendix burst before or during surgery.
Choice D rationale
Pain at the operative site is expected after an appendectomy. However, severe or increasing pain could indicate a complication and should be evaluated by a healthcare provider.
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