ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 48 : Caring for Clients With Ostomies Questions
Question 1 of 5
What potentially life-threatening complication can the client have if corticosteroids are abruptly withdrawn or the client has significant stress due to the impending surgical procedure?
Correct Answer: D
Rationale: Adrenal crisis is potentially life-threatening and can result from the abrupt withdrawal of corticosteroids or significant stress after the client has been treated with corticosteroids. Cushing's disease is a condition caused by increased levels of cortisol. Myxedema coma is a result of dangerously decreased levels of thyroid hormone. Thyroid storm is a life-threatening condition caused by excessive thyroid hormone.
Question 2 of 5
A client scheduled for a total colectomy has been taking the immunosuppressive agent, azathioprine. As part of the nurse's preoperative teaching, when should the client be told to discontinue the medication to prevent negative effects on tissue healing?
Correct Answer: C
Rationale: Immunosuppressive agents such as azathioprine, 6-mercaptopurine, and cyclosporine should be discontinued 3 to 4 weeks before surgery to prevent negative effects on tissue healing. Aspirin-containing compounds are discontinued at least 1 week before surgery to decrease the risk of bleeding.
Question 3 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 4 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 5 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.