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
A. Blood in the urine (hematuria) is not typically associated with urinary retention but can indicate other conditions such as infection or trauma.
B. Cloudy urine may indicate infection but is not a direct sign of urinary retention.
C. Leakage of urine, or overflow incontinence, occurs when the bladder becomes overly full due to retention and releases small amounts of urine involuntarily.
D. Dark-colored urine typically indicates dehydration, which is not a specific sign of urinary retention.
Correct Answer is A
Explanation
A. Pressure points are critical to assess when evaluating skin integrity, particularly in patients who are immobile or bedridden, as these areas are at high risk for pressure ulcers.
B. Breath sounds are important but are not the priority in assessing skin integrity.
C. Pulse points assess circulation, but they are not directly related to skin integrity.
D. Bowel sounds are relevant for digestive assessments, not for skin integrity.
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