Nokea
Which of the following assessment data might indicate the patient is having difficulty accepting his or her new colostomy?
- A. Asks questions about how to take care of the colostomy
- B. Observes as you irrigate the colostomy
- C. Looks at stoma and makes good eye contact with you during ostomy care
- D. Refuses to attempt care, and tells you to ?just do it?
Correct Answer: D
Rationale: Refusing to participate in colostomy care and avoiding involvement can indicate poor acceptance or denial of the new body change. This behavior suggests the patient may be struggling emotionally or psychologically with the colostomy and needs further support or counseling.
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Which of the following factors is most likely to result in diarrhea?
- A. Loss of intestinal normal flora
- B. Drinking excessive fluids
- C. Administration of opioid narcotics
- D. Manipulation of intestines during colon surgery
- E. Eating 10 to 15 g of fiber per day
Correct Answer: A,D
Rationale: Loss of normal flora (e.g., from antibiotics) and surgical manipulation can disrupt bowel function, leading to diarrhea.
What of the following would be the best enema to administer to a patient before digital removal of an impaction?
- A. Siphon enema
- B. Oil retention enema
- C. Soapsuds enema
- D. Harris flush enema
Correct Answer: B
Rationale: An oil retention enema softens the fecal mass, facilitating easier and safer digital removal of an impaction.
The patient is to receive a cleansing enema for relief of constipation. Which of the following factors must be assessed prior to administration of the enema?
- A. Type of solution to administer
- B. Date of last bowel movement
- C. Type of diet the patient has been receiving
- D. Assessment of bowel sounds
- E. The patient's temperature
Correct Answer: B,D
Rationale: Assessing the last bowel movement and bowel sounds ensures the enema is appropriate and safe for the patient.
Which of the following signs and symptoms may be an indication of vagal stimulation during the digital removal of an impaction?
- A. Complaint of rectal pressure
- B. Pulse rate of 42 beats per minute
- C. Complaint of difficulty breathing
- D. Moist skin
- E. Complaint of abdominal cramping
- F. Complaint of feeling faint
Correct Answer: B,F
Rationale: Vagal stimulation can cause bradycardia (pulse 42 bpm) and syncope (feeling faint) due to vagus nerve activation.
Which of the following would be the most accurate statement about digestion and elimination?
- A. All individuals have at least one bowel movement daily
- B. An infant may have up to six bowel movements daily
- C. GI peristalsis increases with age, making incontinence a normal finding
- D. A stool is only considered normal if the color is a shade of brown
Correct Answer: B
Rationale: Infants may have up to six bowel movements daily due to their immature digestive systems.