A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Intestinal obstruction
Folate deficiency
Malabsorption of fat
Fluid and electrolyte imbalance
The Correct Answer is D
Choice A Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.
Choice B Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.
Choice C Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.
Choice D Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect. Inability to perform within normal limits is a vague and general term that does not describe the specific finding of left facial droop. The nurse should document the exact observation and compare it to the expected or normal range.
Choice B Reason: This choice is incorrect. Symmetrical findings mean that both sides of the body or face are equal or similar in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is not symmetrical.
Choice C Reason: This is the correct choice. Asymmetrical findings mean that both sides of the body or face are unequal or different in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is asymmetrical.
Choice D Reason: This choice is incorrect. Bilateral strength present means that both sides of the body or face have normal or adequate muscle power or force. Left facial droop indicates that one side of the face has reduced or impaired muscle power or force, which is not bilateral strength present.
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