Which action will the nurse take when assessing a patient with possible oral cancer?

Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.

Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.

Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.

Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.

Choice A reason: A new ileal conduit is a permanent life change that requires the client to learn complex self-care skills. The uncertainty regarding stoma management, fear of appliance leakage in public, and the lifestyle adjustments required often lead to significant anxiety. The nurse must address these psychological stressors during the initial postoperative period to promote successful adaptation.

Choice B reason: The continuous drainage of urine from the stoma creates a high risk for peristomal skin breakdown. Urine is caustic to the skin, and moisture trapped under the skin barrier can lead to maceration, dermatitis, or fungal infections. Maintaining a secure, well-fitted appliance and assessing the skin frequently are essential nursing interventions for this risk.

Choice C reason: Surgical creation of an ileal conduit involves bowel resection and ureteral implantation, increasing the risk for peritonitis or wound infection. Furthermore, since the conduit is a direct pathway to the kidneys without a sphincter, the client is at lifelong risk for ascending urinary tract infections or pyelonephritis requiring vigilant monitoring.

Choice D reason: While postoperative patients require fluid monitoring, an ileal conduit does not typically cause a chronic fluid volume deficit. Unlike an ileostomy, where significant water and electrolytes are lost through liquid stool, the ileal conduit simply transports urine. Unless there is excessive surgical bleeding or unrelated dehydration, this is not a primary risk.

Choice E reason: The permanent diversion of urine to an external pouch on the abdomen significantly alters the client's physical appearance and "normal" elimination process. Concerns regarding sexual function, clothing choices, and the presence of a stoma frequently lead to a disturbed body image, necessitating supportive counseling and referral to an ostomy nurse.