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A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal?
- A. Patient will accurately identify foods that trigger symptoms.
- B. Patient will demonstrate appropriate care of his ileostomy.
- C. Patient will demonstrate appropriate use of standard infection control precautions.
- D. Patient will adhere to recommended guidelines for mobility and activity.
Correct Answer: A
Rationale: A major focus of nursing care for the patient with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the patient than managing physical activity.
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A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions?
- A. Aim to eventually empty the pouch every 90 minutes.
- B. Avoid emptying the pouch until it is visibly full.
- C. Insert the catheter approximately 5 cm into the pouch.
- D. Aspirate the contents of the pouch using a 60 mL piston syringe.
Correct Answer: C
Rationale: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.
A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize?
- A. Ineffective Tissue Perfusion Related to Bowel Ischemia
- B. Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption
- C. Anxiety Related to Bowel Obstruction and Subsequent Hospitalization
- D. Impaired Skin Integrity Related to Bowel Obstruction
Correct Answer: A
Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.
A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
- A. Administering bowel stimulants as ordered
- B. Administering bulk-forming laxatives as ordered
- C. Performing deep palpation as ordered to promote peristalsis
- D. Preparing the patient for surgical bowel resection
Correct Answer: D
Rationale: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
- A. Spinach
- B. Tofu
- C. Multigrain bagel
- D. Blueberries
Correct Answer: B
Rationale: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of these criteria. Spinach, multigrain bagels, and blueberries are not low-residue.
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
- A. Encourage the patient to conduct online research into colostomies.
- B. Engage the patient in the care of the ostomy to the extent that the patient is willing.
- C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.
- D. Emphasize the fact that the colostomy is temporary measure and is not permanent.
Correct Answer: B
Rationale: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image, since the benefits are likely already known. Online research is not likely to enhance the patients body image and some ostomies are permanent.