Nokea
Because bowel contents from an ileostomy are virtually liquid, which does the nurse expect to see in the plan of care?
- A. Evaluation and assessment of dietary intake of fiber
- B. Evaluation and assessment of patient cleanliness
- C. Evaluation and assessment of peristomal skin integrity
- D. Evaluation and assessment of the adequacy of the collection device
Correct Answer: C
Rationale: The nurse should assess the peristomal skin for impairment of integrity. The fecal material is liquid and has a potential for severe skin excoriation from the digestive enzymes.
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The home health nurse is caring for a patient who has frequent bouts of diverticulitis accompanied by increased flatulence, diarrhea, and nausea. Which is the most appropriate suggestion to lessen these symptoms?
- A. Eat a diet high in fiber content.
- B. Increase dietary fat intake.
- C. Exercise to increase intraabdominal pressure.
- D. Take daily laxatives.
Correct Answer: A
Rationale: The symptoms of diverticulitis can be reduced or prevented by eating a high-fiber diet, reduction of meat and fats in the diet, and avoiding activities that increase intraabdominal pressure. Although laxatives might be prescribed sparingly, daily laxatives are not recommended.
Which will be the most helpful nursing intervention to increase the comfort of a patient with appendicitis?
- A. Applying of ice bag
- B. Administration of small tap water enema
- C. Warm compress over entire abdomen
- D. Ambulate for short periods in the room
Correct Answer: A
Rationale: Applying of an ice bag will decrease the flow of blood to the area and impede the inflammatory process.
What is the most lethal complication of a peptic ulcer?
- A. Bleeding
- B. Perforation
- C. Severe pain
- D. Gastric outlet obstruction
Correct Answer: B
Rationale: Perforation is considered the most lethal complication of peptic ulcer. Bleeding may occur when the ulcer erodes into a blood vessel; however, perforation occurs when the ulcer crater penetrates the entire thickness of the wall of the stomach or duodenum. Gastric outlet obstruction can occur at any time and can be relieved by NG aspiration of stomach contents.
Which activities should the home health nurse suggest to an older adult patient to avoid constipation?
- A. Schedule toileting after meals
- B. Taking bulk-forming laxatives
- C. Increasing fiber intake
- D. Drinking at least 1000 mL fluid
- E. Taking a daily stool softener
- F. Using tap water enemas for persons with altered mobility
Correct Answer: A,B,C,D
Rationale: Inactivity and changes in diet and fluid intake can contribute to constipation. A nutritional diet high in fiber and bulk-forming foods can promote normal elimination. Increasing fluids to 8 to 10 glasses per day will be beneficial in preventing constipation. A daily bowel routine will also benefit elimination. Use of daily stool softeners is no longer recommended for the older adult. Tap water enemas for persons with altered mobility are not routine.
The nurse explains that the chief enzyme of gastric juice, is activated by hydrochloric acid to begin digestion of protein.
- A. pepsin
Correct Answer: pepsin
Rationale: Pepsin is activated by the hydrochloric acid to break down protein for digestion.