A nurse is caring for a light-skinned client who has an ileostomy.
The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.
The nurse is reviewing the client's medical record.
Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.
Day 1:
- Abdomen soft, nondistended.
- Ileostomy present. Stoma is red.
- Stoma draining brown liquid stool
- Client will not look at stoma
Client states they are not interested in learning about stoma care
Day 2:
- Ileostomy pouch changed.
- Skin surrounding stomas reddened and has small open areas
- stoma with small amount of bleeding noted during cleaning.
Client will not look at stoma
Client states they are not interested in learning about stoma care
Skin surrounding stomas reddened and has small open areas
Ileostomy pouch changed.
stoma with small amount of bleeding noted during cleaning.
Abdomen soft, nondistended
Ileostomy present. Stoma is red.
The Correct Answer is ["A","B","C"]
The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.
A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.
Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased thirst is more commonly associated with dehydration or conditions like diabetes, not urinary tract infections (UTIs).
B. Chest pain is unrelated to UTIs and is more concerning for cardiac issues.
C. Fever can occur with more severe or systemic infections (such as pyelonephritis), but it is not a primary or early symptom of a simple UTI.
D. Painful urination (dysuria) is a hallmark symptom of a urinary tract infection, commonly experienced due to irritation and inflammation of the urinary tract.
Correct Answer is C
Explanation
A. The head of the bed should be elevated no more than 30° to prevent shearing forces on the skin.
B. Baby powder can cause dryness and irritation rather than protecting the skin.
C. Lifting rather than pulling reduces the risk of friction and shearing forces, which can lead to skin breakdown and pressure ulcers.
D. Massaging reddened skin over bony prominences can damage already compromised tissue and increase the risk of pressure ulcers.
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