The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

There will be blood and mucus initially exiting the stoma.

The stoma will shrink a bit over a period of weeks.

The stool will be of normal consistency and color.

The stoma should be beefy red.

Drainage will begin approximately 24-48 hours following surgery.

Answer and Explanation

Correct Answer : A,B,D,E

Pre-operative education is successful when the client states that there will be blood and mucus initially exiting the stoma, the stoma will shrink a bit over a period of weeks, the stoma should be beefy red, and drainage will begin approximately 24-48 hours following surgery. These statements indicate that the client has a good understanding of what to expect after surgery.

Option C, The stool will be of normal consistency and color, is not a correct answer as the stool from an ostomy is different from normal stool consistency and color.

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Correct Answer is C

Explanation

Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.

A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.

B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.

D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.

A. Palpation. B. Inspection. C. Auscultation. D. Percussion.

Correct Answer is B

Explanation

Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.

A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.

C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.

D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.

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The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Correct Answer is C

Explanation

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)

Correct Answer is B

Explanation

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