Nokea
The nurse is caring for a patient with an exacerbation of ulcerative colitis who is having 15-20 stools daily and has external hemorrhoids. Which of the following patient behaviours indicate that teaching regarding maintenance of skin integrity has been effective?
- A. The patient uses incontinence briefs to contain loose stools.
- B. The patient asks for antidiarrheal medication after each stool.
- C. The patient uses witch hazel compresses to decrease anal discomfort.
- D. The patient cleans the perianal area with soap and water after each stool.
Correct Answer: C
Rationale: Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15-20 times a day. The perianal area should be washed with plain water after each stool.
You may also like to solve these questions
The nurse is providing patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD). Which of the following diet choices by the patient indicates a need for more teaching?
- A. Scrambled eggs
- B. White toast and jam
- C. Oatmeal with cream
- D. Pancakes with syrup
Correct Answer: C
Rationale: During acute exacerbations of IBD, the patient should be on a low-residue diet and avoid high-fibre foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.
Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. Which of the following explanations should the nurse provide to the patient about this test?
- A. It confirms the diagnosis of colon cancer.
- B. It monitors the tumour status after surgery.
- C. It identifies the extent of cancer spread or metastasis.
- D. It determines the need for postoperative chemotherapy.
Correct Answer: B
Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.
The nurse is caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 4.5 kg over 2 months. Which of the following topics should the nurse plan to include in the teaching plan?
- A. Medication use
- B. Fluid restriction
- C. Enteral nutrition
- D. Activity restrictions
Correct Answer: A
Rationale: Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.
Which of the following nursing actions is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?
- A. Teach about a low-residue diet.
- B. Monitor output from the stoma.
- C. Assess the perineal drainage and incision.
- D. Encourage acceptance of the colostomy stoma.
Correct Answer: C
Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.
Which of the following actions should the nurse implement when initiating the initial plan of care for a patient admitted with acute diverticulitis?
- A. Give stool softeners.
- B. Administer IV fluids.
- C. Order a diet high in fibre and fluids.
- D. Prepare the patient for colonoscopy.
Correct Answer: B
Rationale: A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fibre and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool