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 ["A","C","E"]
Explanation
Choice A rationale
Immobility is a significant risk factor for DVT as it can lead to stagnation of blood in the veins, increasing the risk of clot formation.
Choice B rationale
High calcium intake is not typically associated with an increased risk of DVT. Instead, factors like immobility, certain medications, and medical conditions are more influential.
Choice C rationale
Oral contraceptive use, especially those containing estrogen, can increase the risk of DVT due to their effect on blood clotting mechanisms.
Choice D rationale
A BMI of 20 is considered within the normal range and is not a risk factor for DVT. Obesity, which is a BMI of 30 or higher, would be a risk factor.
Choice E rationale
Hypertension itself is not a direct risk factor for DVT. However, it can be associated with other health conditions that may increase the risk of thrombosis.
Correct Answer is C
Explanation
Choice A rationale
Hemorrhage refers to bleeding, which can be a serious complication of peptic ulcer disease but does not lead to the spilling of gastric contents into the peritoneal cavity.
Choice B rationale
Dumping syndrome is a condition where food moves too quickly from the stomach to the small intestine, which can cause symptoms like nausea and abdominal pain, but it does not involve the leakage of gastric contents into the peritoneal cavity.
Choice C rationale
Perforation is the correct answer because it describes a hole forming in the wall of the stomach or duodenum, allowing gastric contents to spill into the peritoneal cavity, leading to peritonitis, which is a severe and life-threatening condition.
Choice D rationale
Gastric outlet obstruction is a blockage at the end of the stomach that prevents contents from entering the small intestine, which can cause vomiting and abdominal pain, but it does not result in the leakage of gastric contents into the peritoneal cavity.
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