A nurse is developing a plan of care for a client who has a new ileal conduit. Which of the following should the nurse include as risks for the client? (Select all that apply.)
Anxiety
Impaired skin integrity
Infection
Fluid volume deficit
Disturbed body image
Correct Answer : B,C,D,E
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
Choice B rationale
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
Choice C rationale
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
Choice D rationale
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
Correct Answer is D
Explanation
Choice A rationale
A regular diet with no added salt may not be sufficient to address the fluid retention associated with acute glomerulonephritis and peripheral edema.
Choice B rationale
While a low-protein, low-potassium diet may be considered for certain kidney conditions, it does not specifically address the fluid and sodium management needed in acute glomerulonephritis with edema.
Choice C rationale
A low-carbohydrate, low-protein diet is not indicated in this scenario as it does not provide the necessary restrictions on sodium and fluid that are required for a child with edema and oliguria due to acute glomerulonephritis.
Choice D rationale
A low-sodium, fluid-restricted diet is most appropriate for a child with acute glomerulonephritis and peripheral edema. This diet helps manage the edema and prevent further fluid overload, which is crucial in the care of this condition.
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