Nokea
The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?
- A. Sunken and hidden stoma
- B. Dark- and bluish-colored stoma
- C. Narrowed and flattened stoma
- D. Protruding stoma
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following substances is most likely to cause gastritis?
- A. Milk
- B. Bicarbonate of soda or baking soda
- C. Enteric-coated aspirin
- D. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct Answer: D
Rationale: The correct answer is D, Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to cause gastritis by irritating the stomach lining. Choice A, Milk, is unlikely to cause gastritis and is actually a common remedy for mild gastritis symptoms. Choice B, Bicarbonate of soda or baking soda, is often used to relieve heartburn and indigestion, not cause gastritis. Choice C, Enteric-coated aspirin, is less likely to cause gastritis compared to NSAIDs because the enteric coating helps protect the stomach lining from irritation.
Which of the following nursing interventions should be implemented to manage a client with appendicitis?
- A. Assessing for pain
- B. Encouraging oral intake of clear fluids
- C. Providing discharge teaching
- D. Assessing for symptoms of peritonitis
Correct Answer: D
Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.
The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:
- A. Watches the nurse empty the colostomy bag
- B. Looks at the ostomy site
- C. Reads the ostomy product literature
- D. Practices cutting the ostomy appliance
Correct Answer: D
Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.
Which of the following factors is believed to be linked to Crohn's disease?
- A. Constipation
- B. Diet
- C. Hereditary
- D. Lack of exercise
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?
- A. Cleanse the peristomal skin meticulously
- B. Take in high-fiber foods such as nuts
- C. Massage the area below the stoma
- D. Limit fluid intake to prevent diarrhea.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.