Nokea
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.
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The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
A client on the psychiatric unit does not get to the dining room to eat because she is continually washing her hands and doesn't finish until after lunch. What should be included in the nursing care plan?
- A. Give the client a choice between eating lunch and performing her ritual.
- B. Tell the client an hour before lunch so she can perform her ritual before lunch.
- C. Discuss the problem with the client and ask her why she washes her hands so long.
- D. Tell the client she cannot wash her hands at all if she is going to be late for lunch.
Correct Answer: B
Rationale: Advance notice allows the client with OCD to complete rituals before lunch, facilitating nutrition without confrontation. Choices, discussions, or bans are less effective.
The nurse is talking with the parent of an adolescent client with suspected bulimia nervosa. Which of the following statements by the client's parent would be consistent with bulimia nervosa?
- A. I have noticed my child cuts food into small pieces and pushes it around the plate.
- B. I found several empty boxes of laxatives in my child's bedroom.
- C. My child has lost 20 lb (9.1 kg) in the past 2 months.
- D. My child has stopped exercising.
Correct Answer: B
Rationale: Laxative abuse is a common purging behavior in bulimia nervosa. Cutting food and pushing it around is more typical of anorexia. Significant weight loss is less common in bulimia, as weight often fluctuates. Reduced exercise isn't characteristic.
The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?
- A. Initiate chest compressions.
- B. Clarify the order with the HCP.
- C. Prepare the client for defibrillation.
- D. Verify the client's wishes with the family.
Correct Answer: B
Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.
A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timoptic should be used with caution in the client with a history of:
- A. Diabetes
- B. Gastric ulcers
- C. Emphysema
- D. Pancreatitis
Correct Answer: C
Rationale: Timolol, a beta-blocker, can exacerbate emphysema by causing bronchoconstriction. Diabetes , ulcers , and pancreatitis are not contraindications.