A nurse is teaching a dent who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?
"Your colostomy will not produce formed steel.”
"You will have a stoma in your left lower abdomen.”
"You should expect your store to be a purple color."
“The end of the stoma will be painful after this procedure.”
The Correct Answer is B
A. "Your colostomy will not produce formed stool.” A sigmoid colostomy produces formed stool because it is at the end of the large intestine, where water is absorbed.
B. "You will have a stoma in your left lower abdomen." A sigmoid colostomy is placed in the left lower quadrant (LLQ) of the abdomen.
C. "You should expect your stoma to be a purple color." A healthy stoma should be pink to red and moist. A purple, dusky, or dark-colored stoma may indicate ischemia and requires immediate evaluation.
D. "The end of the stoma will be painful after this procedure." The stoma itself does not have nerve endings, so it should not be painful. However, the surrounding abdominal incision may be sore.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The client's ammonia level is critically elevated (250 mcg/dL), which can lead to altered mental status, confusion, and lethargy, consistent with hepatic encephalopathy. In cirrhosis, the liver loses its ability to detoxify ammonia, leading to its accumulation in the bloodstream. This excess ammonia crosses the blood-brain barrier, impairing neuronal function and causing hepatic encephalopathy.
Incorrect answers:
DKA is characterized by high blood glucose (>250 mg/dL), metabolic acidosis, and ketonemia. This client has a moderate glucose elevation (148 mg/dL) but no signs of acidosis, Kussmaul respirations, or ketonuria.
Dehydration: While dehydration can contribute to mental status changes, severe hyperammonemia is a direct cause of hepatic encephalopathy. The client's crackles in the lungs and peripheral edema suggest fluid retention, not dehydration.
Acute kidney disease presents with rising creatinine levels, oliguria, and electrolyte imbalances. This client’s creatinine level is normal, ruling out acute kidney disease.
Malnutrition is characterized by low albumin, muscle wasting, and weight loss, but this client's elevated glucose is more likely due to diabetes mellitus rather than malnutrition.
Correct Answer is A
Explanation
A. Reduce the client's intake of protein: Protein metabolism produces ammonia, which worsens hepatic encephalopathy. Reducing dietary protein (especially red meat) helps lower ammonia levels. However, some protein is necessary, so a diet high in plant-based protein is preferred.
B. Administer vitamin K: Vitamin K is used to manage coagulopathy in liver disease but does not affect ammonia levels.
C. Restrict the client's intake of fluids: Fluid restriction is necessary for hyponatremia or ascites, but it does not help reduce ammonia levels.
D. Administer diuretics: Diuretics are used for ascites and edema, not ammonia reduction.
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