Solutions - Chapter 49 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?
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1ACT. You learn that Mrs. Brown's stools have been liquid, in very small amounts, and at infrequent intervals, generally occurring when She feels the urge to defecate. What additional data are important to obtain from her?
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1TYK. Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
1.  Constipation
2.  Diarrhea
3.  Incontinence
4.  Hemorrhoids
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2ACT. What nursing intervention is most appropriate Before making suggestions to correct or prevent the problem she is experiencing?
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2TYK. Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?
1.  “I need to drink one and a half to two quarts of liquid each day.”
2.  “I need to take a laxative such as Milk of Magnesia if I don’t have a BM every day.”
3.  “If my bowel pattern changes on its own, I should call you.”
4.  “Eating my meals at regular times is likely to result in regular bowel movements.”
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3ACT. What suggestions can you give her about maintaining a regular bowel pattern?
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3TYK. A client is scheduled for a colonoscopy. The nurse will provide information to the
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4ACT. Explain why cathartics and laxatives are generally contraindicated for people in Mrs. Brown’s situation?
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4TYK. The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
1.  The stoma extends 1/2 in. above the abdomen.
2.  The skin under the appliance looks red briefly after removing the appliance.
3.  The stoma color is a deep red-purple.
4.  The ascending colostomy delivers liquid feces.
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5TYK. Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?
1.  The client will wear a medical alert bracelet for antibiotic allergy.
2.  The client will return to his or her previous fecal elimination pattern.
3.  The client will verbalize the need to take an antidiarrheal medication pm.
4.  The client will increase intake of insoluble fiber such as grains, rice, and cereals.
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6TYK. A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?
1.  Prepare to irrigate the colostomy.
2.  After assessing the stoma and surrounding skin, notify the surgeon.
3.  Assess bowel sounds and administer antiemetic.
4.  Administer a bulk-forming laxative, and encourage increased fluids and exercise.
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7TYK. The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated.” The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
1.  Soapsuds
2.  Retention
3.  Return flow
4.  Oil retention
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8TYK. Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
1.  Large quantities of fat mixed with pale yellow liquid stool
2.  Brown, formed stools
3.  Semisoft black-colored stools
4.  Narrow, pencil-shaped stool
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9TYK. Which nursing diagnoses is/are most applicable to a client fecal incontinence? Select all that apply.
1.  Bowel Incontinence
2.  Risk for Deficient Fluid Volume
3.  Disturbed Body Image
4.  Social Isolation
5.  Risk for Impaired Skin Integrity
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