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A nurse cares for a client with a new ileostomy. The client states, 'I don't think my friends will accept me with this ostomy.' How should the nurse respond?
- A. Your friends will be happy you are alive.
- B. Tell me more about your concerns.
- C. A therapist can help you resolve your concerns.
- D. With time you will accept your new body.
Correct Answer: B
Rationale: Encouraging the client to express concerns addresses social anxiety and apprehension common with a new ostomy. Minimizing concerns, suggesting a therapist without discussion, or assuming acceptance over time are not therapeutic responses.
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A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Pale and bluish stoma
- B. Liquid stool
- C. Ostomy pouch intact
- D. Blood-smeared output
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Distended abdomen
- B. Temperature of 100.0°F (37.8°C)
- C. Loose and bloody stool
- D. Abdominal cramps
Correct Answer: A
Rationale: Colonic strictures predispose the client to intestinal obstruction. A distended abdomen may indicate an obstruction, requiring urgent notification of the provider. Low-grade fever, loose and bloody stools, and abdominal cramps are common symptoms of Crohn's disease and do not require immediate intervention.
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
- A. Metronidazole (Flagyl)
- B. Ciprofloxacin (Cipro)
- C. Sulfasalazine (Azulfidine)
- D. Ceftriaxone (Rocephin)
Correct Answer: A
Rationale: Metronidazole is the drug of choice for Giardia, a parasitic infection. Ciprofloxacin and ceftriaxone treat bacterial infections, and sulfasalazine is used for ulcerative colitis or Crohn's disease, not Giardia.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
- A. Lower gastrointestinal bleeding - Erosion of the bowel wall
- B. Abscesses - Localized pockets of infection develop in the ulcerated bowel lining
- C. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria
- D. Non-mechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer
- E. Fistulas - Dilation and decreased motility caused by paralysis of the colon
Correct Answer: A,B,D
Rationale: Lower GI bleeding results from bowel wall erosion, abscesses form in ulcerated bowel lining, and non-mechanical bowel obstruction occurs due to colon paralysis from colorectal cancer. Toxic megacolon involves colon dilation, not pyuria/fecaluria, and fistulas result from transmural inflammation, not paralysis.
After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?
- A. I realize that you had a tough time today, but it will get easier with practice.
- B. You cleared the stoma well. Now you need to practice putting on the appliance.
- C. You seem to understand what I taught you today. What else can I help you with?
- D. You seem to understand. Do you want your daughter to care for your ostomy?
Correct Answer: B
Rationale: Feedback should be objective and constructive, acknowledging what was done well (clearing the stoma) and identifying areas for improvement (applying the appliance). General reassurance, vague inquiries, or suggesting someone else manage the ostomy are not constructive.