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 C
Explanation
A. The child has taken phenytoin medication for seizures: Phenytoin use is not associated with the development of arteriovenous malformations. Anticonvulsants do not increase AVM risk; they are prescribed to manage seizure activity, which may occur if an AVM is already present.
B. The child is a 6-year-old female: Age and sex alone are not considered risk factors for AVMs. While AVMs can present in childhood, there is no significant predilection based solely on being female or the child’s age.
C. The child has a genetic history of Hippel-Lindau disease: Genetic disorders such as Hippel-Lindau disease are associated with increased risk of vascular malformations, including AVMs. Recognizing a family or personal history of these conditions is essential in assessing risk.
D. The client smoked while they were pregnant with the child: Maternal smoking is linked to low birth weight and certain congenital defects, but it is not a known risk factor for the development of arteriovenous malformations.
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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