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 C
Explanation
Rationale:
A. Drinking plenty of water helps to flush bacteria from the urinary tract, reducing the risk of a UTI.
B. Good personal hygiene reduces the risk of UTIs by preventing bacterial contamination.
C. Urinary catheters provide a direct pathway for bacteria to enter the bladder, increasing the risk of UTIs.
D. Frequent handwashing is a preventive measure but not directly related to the development of UTIs.
Correct Answer is B
Explanation
A. Withholding pain medication could result in increased discomfort, which may further hinder the patient’s ability to defecate.
B. Raising the head of the bed promotes a more natural position for defecation, making it easier for the patient to use the bedpan.
C. Administering laxatives may be necessary in some cases but is not the first intervention to assist with positioning and comfort during defecation.
D. A barium enema is a diagnostic tool, not an appropriate intervention for immediate defecation assistance.
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