Nokea
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?
- A. The client will be given instructions on how to care for the ostomy.
- B. The client will demonstrate adequate coping skills.
- C. The client will be allowed time and support to promote communication.
- D. Client verbalizes what the changes will be and the benefits to future health.
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.
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The nurse is caring for a client in the immediate postoperative phase after having a colostomy created. What type of appliance should the nurse use at this time?
- A. A reusable pouch appliance should be used.
- B. A disposable or temporary appliance should be used.
- C. A dry sterile dressing should be used over the stoma.
- D. A wet to dry dressing should be used over the stoma to keep it moist.
Correct Answer: B
Rationale: A disposable, or temporary, appliance is preferred in the immediate postoperative phase because the size of the stoma changes over time as a result of swelling from the procedure itself. The size of the stoma may change rapidly and differ from one appliance change to the next. After the stoma heals and reaches its final size and shape, a permanent appliance (reusable) may be used. A dry sterile dressing or wet to dry dressing should not be placed over the stoma due to the saturation of stool, which may cause maceration of the skin around the stoma.
A client who is scheduled for an ileostomy surgery says to the nurse, 'I'm afraid I won't be able to look at that stoma.' Which response by the nurse would be most therapeutic?
- A. That's something you don't have to think about now.'
- B. I'll make sure there is a familiar nurse here with you the first time.'
- C. It's okay, everybody feels this anxious about this.'
- D. Don't worry, I'm sure that you will be able to do this just fine.'
Correct Answer: B
Rationale: Telling the client that a familiar nurse will be with him the first time provides the client with reassurance that he will not be alone and will have the support of a familiar person to answer questions and provide comfort and support. Telling the client not to worry about it now, that everybody feels anxious, and that he'll do just fine discounts the client's feelings and is not therapeutic.
The nurse is preparing to irrigate a client's single-barrel colostomy after surgery. The nurse would expect an order from the healthcare provider to irrigate the colostomy on what day after surgery?
- A. Fourth or fifth postoperative day
- B. The day after surgery
- C. The seventh postoperative day
- D. The colostomy should be irrigated immediately postop
Correct Answer: A
Rationale: Colostomy irrigation begins on the fourth or fifth postoperative day. Standard irrigation is a scheduled irrigation, using 500 to 1500 mL of tepid water.
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?
- A. Cushing's disease
- B. Myxedema coma
- C. Thyroid storm
- D. Adrenal crisis
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.
The nurse is preparing a client for surgery and observes on the operative permit that the client will be having a double-barrel colostomy. The nurse explains to the client's spouse that this is performed on what portion of the large intestine?
- A. Descending
- B. Ascending
- C. Transverse
- D. Sigmoid
Correct Answer: C
Rationale: A double-barrel colostomy, which is performed most often in the transverse section of the large intestine, contains both a proximal and distal stoma.