Nokea
A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had no ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses priority action?
- A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse.
- B. Report signs and symptoms of obstruction to the physician.
- C. Encourage the patient to mobilize to enhance motility.
- D. Contact the physician and obtain a swab of the stoma for culture.
Correct Answer: B
Rationale: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem.
You may also like to solve these questions
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 patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?
- A. Annual screening colonoscopies
- B. Adherence to recommended immunization schedules
- C. Regular blood pressure monitoring
- D. Frequent screening for osteoporosis
Correct Answer: D
Rationale: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring.
The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?
- A. Recurrent constipation coupled with weight loss
- B. Foul-smelling diarrhea that contains fat
- C. Fever accompanied by a rigid, tender abdomen
- D. Bloody bowel movements accompanied by fecal incontinence
Correct Answer: B
Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.
During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
- A. Regular application of an OTC antibiotic ointment
- B. Increased fluid and fiber intake
- C. Daily use of OTC glycerin suppositories
- D. Use of an NSAID to reduce inflammation
Correct Answer: B
Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient?
- A. Acute Pain Related to Increased Peristalsis and GI Inflammation
- B. Activity Intolerance Related to Generalized Weakness
- C. Bowel Incontinence Related to Increased Intestinal Peristalsis
- D. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
- E. Impaired Urinary Elimination Related to GI Pressure on the Bladder
Correct Answer: A,B,D
Rationale: Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is not directly influenced.