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During a home visit, the client’s spouse reports that since her husband’s placement of a colostomy 3 months ago, he has lost interest in golf. She also says he cries often for no reason, sleeps for only a few hours at night, and reports fatigue. The wife asks the nurse for advice. Which statement should be the basis for the nurse’s response?
- A. One in four clients develops depression after ostomy surgery.
- B. Athletic activities like golf are not possible after ostomy surgery.
- C. After 3 months the client should have accepted his new body image.
- D. The smell and location make it difficult to sleep well with an ostomy.
Correct Answer: A
Rationale: The client is exhibiting signs of depression. At least 25% of clients develop clinically significant depression following colostomy. Poor adjustment to a stoma correlates to development of depression.
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The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis?
- A. My pain goes away when I have a bowel movement.
- B. I have bright red blood in my stool all the time.
- C. I have episodes of diarrhea and constipation.
- D. My abdomen is hard and rigid and I have a fever.
Correct Answer: C
Rationale: Crohn's disease often causes alternating diarrhea and constipation due to inflammation and strictures throughout the GI tract. Pain relief after bowel movements is less specific, bright red blood is more typical of ulcerative colitis, and a rigid abdomen suggests complications.
The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?
- A. The sodium level.
- B. The albumin level.
- C. The potassium level.
- D. The glucose level.
Correct Answer: C
Rationale: Potassium is critical to monitor in diarrhea due to risk of hypokalemia from losses, which can cause arrhythmias. Sodium is also relevant, but potassium is priority.
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.
An upper GI series is ordered for a client. Which action is essential for the nurse before the test?
- A. Check to see if the client has an allergy to shellfish.
- B. Instruct the client to have nothing to eat after midnight the night before the test.
- C. Encourage the client to drink plenty of liquids before the test.
- D. Be sure the client does not eat fat-containing foods for 18 hours before the test.
Correct Answer: B
Rationale: Preparation for an upper GI series requires NPO for eight hours to ensure a clear view of the GI tract. Shellfish allergies are irrelevant as iodine dye is not used, and fat restriction applies to gallbladder tests.
The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?
- A. Assess the abdomen for a tympanic wave.
- B. Monitor the client's blood pressure.
- C. Percuss the liver for size and location.
- D. Weigh the client twice each week.
Correct Answer: B
Rationale: Monitoring blood pressure detects complications of portal hypertension, like variceal bleeding. Tympanic wave is incorrect, liver percussion is less urgent, and weight checks are secondary.