The nurse is caring for a patient with inflammatory bowel disease who has been discharged with an ileostomy. The patient expresses reluctance to participate in aspects of ostomy care.

What is the nurse's most appropriate response to this observation?

Remind the patient that they will be responsible for caring for the ileostomy after discharge.

Reassure the patient that this procedure will be reversed in a few months.

Acknowledge the patient's reluctance and initiate discussion to explore their feelings.

Discuss with the medical team during interdisciplinary rounds the need for a psychiatric referral.

Answer and Explanation

The Correct Answer is C

Choice A reason: Reminding the patient that they will be responsible for caring for the ileostomy after discharge may increase their anxiety and reluctance. It does not address the underlying concerns or feelings.

Choice B reason: Reassuring the patient that the procedure will be reversed in a few months is not always accurate and may provide false hope. Each patient's situation is unique, and not all ileostomies are temporary.

Choice C reason: Acknowledging the patient's reluctance and initiating a discussion to explore their feelings is the most appropriate response. This approach allows the nurse to understand the patient's concerns, provide emotional support, and offer practical solutions to help the patient feel more comfortable with ostomy care.

Choice D reason: Discussing the need for a psychiatric referral during interdisciplinary rounds is not the immediate step. The nurse should first address the patient's feelings and concerns directly and provide support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

A. Fruity-smelling breath B. Sweating and nervousness C. Nausea and vomiting D. Increased thirst and urination

Correct Answer is B

Explanation

Choice A reason: Fruity-smelling breath is a symptom of ketoacidosis, not hypoglycemia. Ketoacidosis occurs when the body produces high levels of ketones due to a lack of insulin, leading to metabolic acidosis.

Choice B reason: Sweating and nervousness are common symptoms of hypoglycemia. Low blood glucose levels trigger the release of adrenaline, which causes these symptoms. Patients should check their blood glucose when experiencing these signs to prevent severe hypoglycemia.

Choice C reason: Nausea and vomiting are more associated with ketoacidosis. High blood glucose levels and the presence of ketones can cause gastrointestinal upset.

Choice D reason: Increased thirst and urination are also symptoms of hyperglycemia and ketoacidosis. These symptoms result from the body's attempt to eliminate excess glucose and ketones through urine.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient with inflammatory bowel disease who has been discharged with an ileostomy. The patient expresses reluctance to participate in aspects of ostomy care. What is the nurse's most appropriate response to this observation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Correct Answer is B

Explanation

The nurse is teaching a patient with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. The patient demonstrates understanding of hypoglycemia by stating they will check their blood glucose when experiencing which of the following symptoms?

Correct Answer is B

Explanation

The nurse is caring for a patient with hyperosmolar hyperglycemic syndrome. The patient is receiving intravenous fluids of normal saline with 20 mEq of potassium chloride and a continuous insulin infusion. Which finding will indicate to the nurse that the treatment is effective?

The nurse is caring for a patient who is being treated for idiopathic thrombocytopenic purpura (ITP). Which treatment will the nurse administer as part of this patient's management?

The nursing instructor is discussing heart failure during post-conference. Which statement by the student confirms their understanding of a contributing factor to a patient's increased risk for developing heart failure?

The nurse is caring for a patient who presents with metabolic alkalosis. Upon assessing the patient, which clinical manifestation will the nurse expect to find?

The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

The nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which lab results will the nurse expect to find to support this diagnosis?

The nurse is caring for a patient with systemic lupus erythematosus (SLE). What health education will the nurse teach the patient to prevent flares and complications of this condition?

The nurse is caring for a patient with inflammatory bowel disease who has been discharged with an ileostomy. The patient expresses reluctance to participate in aspects of ostomy care.

What is the nurse's most appropriate response to this observation?