chapter 26 - Chapter 26: The Patient with an Ostomy...

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Chapter 26: The Patient with an Ostomy MULTIPLE CHOICE 1. The nurse explains that an artificial opening into a body cavity is a(n): 1. gastrostomy. 2. ostomy. 3. colonoscopy. 4. ureterostomy. ANS: 2 An ostomy is an artificial opening into a body cavity. PTS: 1 DIF: Cognitive Level: Knowledge REF: 396 OBJ: 3 TOP: Terminology KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2. The colostomy patient is instructed to measure the width of the stomas for the first 6 weeks postoperatively before applying each new pouch because: 1. the stoma will shrink during this time. 2. a poor-fitting pouch will cause infection of the stoma. 3. the paste will not adhere. 4. prolapse will result. ANS: 1 During the first 6 weeks, the stoma normally shrinks. The pouch needs to fit as closely to the stoma as is comfortable and safe to prevent skin irritation. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: 4 TOP: Pouch Fit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A 47-year-old patient who is 3 days postsurgery with a permanent colostomy reports some abdominal discomfort and abdominal rigidity. The assessment that the nurse should report and record is: 1. vital signs—temperature, 100; pulse, 92; blood pressure, 160/98. 2. stoma is swollen and red; small amount of blood at base. 3. pouch drainage of 110 mL green-brown liquid, oozing from pouch edges. 4. stoma is protruding. ANS: 1 Vital signs in conjunction with complaint of abdominal discomfort should be reported and recorded as possible signs of impending peritonitis. PTS: 1 DIF: Cognitive Level: Application REF: 403 OBJ: 4 TOP: Signs of Peritonitis in a Postoperative Colostomy Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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4. The nurse is aware that many ostomates have an altered self-image, which may cause: 1. self-care deficits. 2. sexual dysfunction. 3. nonadherence to diet. 4. irrational anger. ANS: 2 A damaged self-image or body image may cause ostomates to feel unattractive and embar- rassed about possible sexual activity. Open-ended questions assist the patient to talk about their feelings. PTS: 1 DIF: Cognitive Level: Application REF: 400 and 410 OBJ: 4, 7 TOP: Self-Concept Issues in an Ostomate KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 5. To ensure a good fit of the appliance to avoid leakage, which of the following should the nurse consider for pouch placement? 1. Place the pouch only when the patient is lying down. 2. The pouch placement should be checked for sitting comfort, standing comfort, and ambulation. 3. The pouch should fit very snugly to edges of stoma. 4. The pouch must cover the entire abdomen. ANS: 2 Placement of the pouch should be comfortable in all positions, but not too snug on the stoma for fear of laceration. The pouch need only cover enough of the abdomen to allow for a firm fit.
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This note was uploaded on 10/14/2010 for the course HNSC HNSC 6.1 taught by Professor Katz during the Spring '10 term at CUNY Brooklyn.

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chapter 26 - Chapter 26: The Patient with an Ostomy...

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