A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure?

Correct Answer: C

Rationale: In the context of a patient with liver failure due to chronic alcohol abuse, the correct answer is C) Abnormal peripheral vasodilation. This is because liver failure can lead to the inability of the liver to metabolize substances properly, resulting in the accumulation of vasodilators like nitric oxide, leading to systemic vasodilation. This vasodilation causes a drop in systemic vascular resistance, resulting in decreased blood pressure. Option A) Hypoalbuminemia is not directly related to blood pressure changes associated with liver failure. While liver failure can lead to decreased production of albumin, hypoalbuminemia is more associated with fluid shifts and edema rather than blood pressure changes. Option B) Increased capillary permeability is not a typical change associated with liver failure. Capillary permeability changes are more commonly seen in conditions like sepsis or severe trauma. Option D) Excess renin release from the kidneys is not a typical finding in liver failure. Renin is usually released in response to low blood pressure or low sodium levels, not directly related to liver dysfunction. Understanding the hemodynamic changes in liver failure is crucial in managing these patients effectively. Monitoring blood pressure closely can help in recognizing and managing complications like hypotension that can arise from abnormal peripheral vasodilation in liver failure.

Correct Answer: A

Rationale: In caring for a patient with a sigmoid colostomy, the correct answer is A) Formed stool. This is because a sigmoid colostomy is typically located in the descending or sigmoid colon, where water absorption primarily occurs. Therefore, the stool that passes through this colostomy tends to be more formed compared to colostomies located higher up in the colon, where more water absorption takes place. Option B) Semisolid and Option C) Semiliquid are incorrect because these consistencies are more commonly associated with colostomies located in the transverse or ascending colon, where less water absorption occurs, resulting in looser stool consistency. Option D) Watery is also incorrect as this consistency is more indicative of colostomies located in the proximal colon or small intestine, where minimal water absorption occurs, leading to watery stool output. Understanding the location of the colostomy and its impact on water absorption and stool consistency is crucial in providing appropriate care for patients with ostomies. Educating nursing students on these principles helps them make informed decisions regarding ostomy care and management based on the specific characteristics of the colostomy.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Yogurt. Yogurt is a good choice for individuals with a colostomy experiencing flatus issues because it contains probiotics that can help regulate the digestive system and reduce gas production. Probiotics promote a healthy balance of gut bacteria, which can improve digestion and decrease bloating and gas. Option A) Peas, Option B) Cabbage, and Option C) Broccoli are high-fiber foods that can increase gas production in individuals with a colostomy. These foods are known to produce more gas during digestion, leading to increased flatulence. Therefore, recommending these options to someone experiencing flatus issues may exacerbate their symptoms rather than alleviate them. From an educational perspective, it is essential for healthcare providers, especially those working with patients with colostomies, to have a good understanding of dietary recommendations that can help manage common issues such as flatus. Encouraging the consumption of yogurt with probiotics not only helps address the immediate concern of excessive gas but also promotes overall digestive health for individuals with colostomies. This knowledge empowers healthcare professionals to provide holistic care that considers both the medical condition and dietary factors impacting the patient's well-being.

Correct Answer: C

Rationale: In teaching ostomy self-care to a patient with a colostomy, it is crucial to ensure the correct sizing of the wafer to promote proper ostomy function and skin integrity. Option C, cutting the wafer about 1/8" larger than the stoma, is the correct choice. This additional space allows for a secure fit around the stoma without putting pressure on it, reducing the risk of leakage and skin irritation. Option A, cutting to the exact size of the stoma, can lead to the wafer being too tight, causing pressure on the stoma and potentially leading to necrosis or skin breakdown. Option B, cutting slightly smaller than the stoma, may not provide enough coverage, leading to leakage issues. Option D, cutting significantly larger than the stoma, can result in poor adhesion, leakage, and skin irritation due to exposed skin. Educationally, understanding the rationale behind correct ostomy wafer sizing is essential for nurses to effectively educate patients on self-care practices. It ensures optimal patient outcomes, promotes independence in managing their ostomy, and prevents complications. Providing clear and accurate instructions empowers patients to maintain their ostomy effectively, improving their quality of life and overall well-being.

Correct Answer: B

Rationale: In medical-surgical nursing, the correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation. This order is crucial for a comprehensive assessment of the gastrointestinal system. Observation allows the nurse to visually assess any abnormalities such as distention or scars. Auscultation comes next to listen for bowel sounds, followed by percussion to assess the presence of gas or fluid in the abdomen. Palpation, the final step, helps to identify tenderness, masses, or organ enlargement. Option A is incorrect because percussion should precede palpation in an abdominal assessment. Option C is incorrect as palpation should come before auscultation. Option D is incorrect because observation should be the first step in the assessment. Educationally, understanding the correct sequence of an abdominal assessment is essential for nurses to accurately identify potential issues and provide appropriate care to their patients. Following the correct order ensures a systematic approach that enhances assessment accuracy and patient outcomes.