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A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
- A. Perform massage of the stoma three times a day.
- B. Include high-fiber foods in the diet, especially nuts.
- C. Limit fluid intake to prevent loose stools.
- D. Cleanse the peristomal skin meticulously.
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (A) is unnecessary, high-fiber foods like nuts (B) may cause blockages, and limiting fluids (C) risks dehydration.
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In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
- A. Clay-colored stools
- B. Steatorrhea stools
- C. Dark brown stools
- D. Blood-tinged stools
Correct Answer: B
Rationale: Clay-colored stools indicate dysfunction of the liver or biliary tract. In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. Dark brown stools indicate normal passage through the colon. Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
- A. Keep breathing with your abdominal muscles as long as you can.
- B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
- C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
- D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Fourth stage of labor
- B. Third stage of labor
- C. Transition stage of labor
- D. Second stage of labor
Correct Answer: C
Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Patience by the child when wearing soiled diapers
- B. Communicating the urge to defecate or urinate
- C. The child awakening wet from his naps
- D. The age at which the child's siblings were trained
Correct Answer: B
Rationale: A child must be able to use verbal or nonverbal skills to communicate needs, indicating readiness for toilet training.
A client with a history of a peptic ulcer is being discharged. The nurse should teach the client to:
- A. Avoid spicy foods
- B. Eat large meals
- C. Lie down after eating
- D. Increase caffeine intake
Correct Answer: A
Rationale: Spicy foods can irritate a peptic ulcer, delaying healing. Small meals, avoiding lying down post-meals, and limiting caffeine are also recommended.