Nokea
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.
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A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the patients care knows that treatment will be chosen based on what risk?
- A. Risk for infection
- B. Risk for bowel incontinence
- C. Risk for constipation
- D. Risk for impaired tissue perfusion
Correct Answer: A
Rationale: Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do not contribute to bowel incontinence, constipation, or impaired tissue perfusion.
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 working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function?
- A. Use glycerin suppositories on a regular basis.
- B. Limit physical activity to promote bowel peristalsis.
- C. Consume high-residue, high-fiber foods.
- D. Resist the urge to defecate until the urge becomes intense.
Correct Answer: C
Rationale: Goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of soaps or pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.
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.
Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy?
- A. Risk for Unstable Blood Glucose Due to Changes in Digestion and Absorption
- B. Unilateral Neglect Related to Decreased Physical Mobility
- C. Risk for Excess Fluid Volume Related to Dietary Changes and Changes In Absorption
- D. Ineffective Sexuality Patterns Related to Changes in Self-Concept
Correct Answer: D
Rationale: The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the physiologic changes that result from colorectal surgery.