Nursing Elites

1. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

• A. Formed
• B. Semisolid
• C. Semiliquid
• D. Watery

Correct answer: A

Rationale: The stool from a sigmoid colostomy is typically formed.

2. Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?

• A. Obesity
• B. Volvulus
• C. Constipation
• D. Intestinal obstruction

Correct answer: B

Rationale: Obesity, constipation, and intestinal obstruction can all lead to increased abdominal pressure, which in turn can cause a hiatal hernia.

3. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

4. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

• A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
• B. Disturbed Sleep Pattern related to epigastric pain
• C. Ineffective Coping related to exacerbation of duodenal ulcer
• D. Activity Intolerance related to abdominal pain

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

5. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

Similar Questions