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A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?
- A. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake
- B. Risk for Infection Related to Possible Rupture of Appendix
- C. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake
- D. Chronic Pain Related to Appendicitis
Correct Answer: B
Rationale: The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.
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A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
- A. Administering bowel stimulants as ordered
- B. Administering bulk-forming laxatives as ordered
- C. Performing deep palpation as ordered to promote peristalsis
- D. Preparing the patient for surgical bowel resection
Correct Answer: D
Rationale: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.
A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
- A. Insertion of a nasogastric tube
- B. Insertion of a central venous catheter
- C. Administration of a mineral oil enema
- D. Administration of a glycerin suppository and an oral laxative
Correct Answer: A
Rationale: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
- A. Development of new hemorrhoids
- B. Abdominal bloating and flank pain
- C. Unexplained weight gain
- D. Change in bowel habits
Correct Answer: D
Rationale: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
- A. Encourage the patient to conduct online research into colostomies.
- B. Engage the patient in the care of the ostomy to the extent that the patient is willing.
- C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.
- D. Emphasize the fact that the colostomy is temporary measure and is not permanent.
Correct Answer: B
Rationale: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image, since the benefits are likely already known. Online research is not likely to enhance the patients body image and some ostomies are permanent.
Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy?
- A. Risk for Unstable Blood Glucose Due to Changes in Digestion and Absorption
- B. Unilateral Neglect Related to Decreased Physical Mobility
- C. Risk for Excess Fluid Volume Related to Dietary Changes and Changes In Absorption
- D. Ineffective Sexuality Patterns Related to Changes in Self-Concept
Correct Answer: D
Rationale: The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the physiologic changes that result from colorectal surgery.