A nurse is providing care to a 6-year-old client who has an ileostomy. Which of the following interventions should the nurse anticipate to support ostomy care?
Assess the stoma site monthly to minimize disruption to the client's routine.
Consult the wound-ostomy team for guidance on treating irritated or broken skin around the stoma.
Change the ostomy appliance daily regardless of the condition of the stoma site.
Empty the ostomy's stool output only when the collection appliance is full to capacity.
The Correct Answer is B
A. Assess the stoma site monthly to minimize disruption to the client's routine: Stoma assessment should be performed at least daily, especially in pediatric clients, to monitor for changes in color, size, and skin integrity, rather than monthly.
B. Consult the wound-ostomy team for guidance on treating irritated or broken skin around the stoma: Involving a wound-ostomy-continence (WOC) nurse ensures specialized care for peristomal skin breakdown and helps prevent complications, which is essential for maintaining the stoma and surrounding tissue.
C. Change the ostomy appliance daily regardless of the condition of the stoma site: Routine daily changes are unnecessary and can irritate the skin. Appliance changes should be based on the condition of the skin and the integrity of the pouch system.
D. Empty the ostomy's stool output only when the collection appliance is full to capacity: Waiting until the appliance is full can increase the risk of leakage, skin breakdown, and odor. It is recommended to empty the pouch when it is one-third to one-half full.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Complete blood count: A CBC provides information about hemoglobin, hematocrit, and red and white blood cell counts, which can reflect nutritional status. Low hemoglobin or hematocrit may indicate iron deficiency anemia, while changes in white blood cells could suggest protein-calorie malnutrition or immune compromise.
B. Cardiac enzymes: Cardiac enzymes, such as troponin and CK-MB, are used to assess myocardial injury and are not related to routine nutritional monitoring in children.
C. Blood coagulation tests: Coagulation studies evaluate clotting function and liver-related disorders. While vitamin K deficiency may affect clotting, these tests are not primary indicators for overall nutritional assessment.
D. Arterial blood gases: ABGs measure acid-base balance and oxygenation status. They are not standard tests for evaluating nutritional status unless there is a specific metabolic concern.
Correct Answer is D
Explanation
A. Tay-Sachs disease is a progressive disease process with a maximum life span of 18 to 20 years: While this statement describes a serious progressive disease, it is inaccurate for Tay-Sachs, as the infantile form typically results in death much earlier, usually by 4–5 years of age, not late adolescence.
B. Having Tay-Sachs disease means their child will never be able to have children of their own: Fertility is not a central concern in the infantile form of Tay-Sachs, and this factor is not a primary contributor to caregiver grief immediately after diagnosis.
C. Having Tay-Sachs disease means their child cannot play sports due to possible heart conditions: Tay-Sachs does not primarily affect cardiac function; restrictions on activities like sports are not the main cause of caregiver distress in this context.
D. Tay-Sachs is a progressive disease in which the child usually dies before years of age: The early-onset form of Tay-Sachs leads to progressive neurodegeneration, loss of motor and cognitive function, and death typically by 4–5 years. Awareness of this prognosis is a major factor contributing to the caregivers’ grief and emotional response.
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