Nokea
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.
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A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?
- A. A 45-year-old teacher who stands for 6 hours per day
- B. A pregnant woman at 28 weeks gestation
- C. A 37-year-old construction worker who does heavy lifting
- D. A 60-year-old professional who is under stress
Correct Answer: B
Rationale: Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.
A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurses most appropriate response to this observation?
- A. Ensure that the patient knows that he or she will be responsible for care after discharge.
- B. Reassure the patient that many people are fearful after the creation of an ostomy.
- C. Acknowledge the patients reluctance and initiate discussion of the factors underlying it.
- D. Arrange for the patient to be seen by a social worker or spiritual advisor.
Correct Answer: C
Rationale: If the patient is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the patient and explore the factors that underlie it. It is presumptive to assume that the patients behavior is motivated by fear. Assessment must precede referrals and emphasizing the patients responsibilities may or may not motivate the patient.
A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?
- A. High levels of alcohol consumption
- B. History of bowel obstruction
- C. History of diverticulitis
- D. Longstanding psychosocial stress
Correct Answer: A
Rationale: Risk factors include high alcohol intake; cigarette smoking; and high-fat, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer.
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 patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
- A. Spinach
- B. Tofu
- C. Multigrain bagel
- D. Blueberries
Correct Answer: B
Rationale: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of these criteria. Spinach, multigrain bagels, and blueberries are not low-residue.