ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 48 : Caring for Clients With Ostomies Questions
Question 1 of 5
A client who will be having a portion of colon removed and colostomy created informs the nurse that he 'will not be attractive any longer.' The nurse determines the nursing diagnosis is Altered Body Image Perception related to the stoma and altered bowel elimination. What expected outcome related to this diagnosis will the client have?
Correct Answer: D
Rationale: For a nursing diagnosis of Altered Body Image Perception, the expected outcome is that the client verbalizes what the changes will be and the benefits to future health. This demonstrates that the client understands and is accepting of the changes that are to occur. Giving instructions is a nursing intervention and not an outcome. Demonstrating adequate coping skills is not a measurable goal, and supporting and promoting communication does not correlate with the nursing diagnosis of Altered Body Image Perception.
Question 2 of 5
A client who had a total colectomy with an ileostomy has rectal packing in place to absorb drainage and promote healing. When the client asks how soon the packing will be removed, what is the nurse's best response?
Correct Answer: C
Rationale: The rectum is packed with gauze during surgery to absorb drainage and promote gradual healing. The rectal pack usually is removed in 5 to 7 days.
Question 3 of 5
The nurse is instructing a client with an ileostomy on appliance and changing it. What statement made by the client demonstrates the client understands using a new appliance for the first time?
Correct Answer: A
Rationale: When using a new adhesive product, the client should patch test it first on nonirritated skin at the inner aspect of the forearm. The most common causes of discomfort are reactions to the adhesive or solvent used to remove it or irritation from leaking fecal drainage. In such cases, the client may experience stinging, tingling, or itching immediately after an appliance change. If a sensation is prolonged or intensified, the client should remove the appliance regardless of whether it has been on for 1 hour or several days. The client should avoid rubbing, which may further irritate skin. If the faceplate is changed too frequently, skin around the stoma may become raw and excoriated secondary to removal of protective layers of epithelium with the faceplate.
Question 4 of 5
A client with an ileostomy tells the nurse that he is having a lot of problems with the formation of gas. What can the nurse tell the client to help her with this a common issue?
Correct Answer: A
Rationale: The client should eat slowly and chew food well with the mouth closed to help lessen the development of gas. Restricting oral intake should only be done with medical supervision and will not help with gas reduction. Enemas should not be administered. The stoma is only dilated when the stool volume decreases.
Question 5 of 5
A client has been discharged from the acute care facility with an ileostomy. The client comes to the clinic for a follow-up visit and informs the nurse that the wound has been draining and they are having abdominal pain and running a fever. What does the nurse suspect is occurring with the client?
Correct Answer: C
Rationale: Signs of wound infection are wound drainage, abdominal pain, and elevated temperature. These symptoms do not indicate an allergic reaction, anemia, or not emptying the pouch correctly.