[Osborn] chapter 45 Learning Outcomes [Number and Title ] Learning Outcome 1 Describe the different causes of stomatitis and related nursing care. Learning Outcome 2 Compare and contrast pathophysiology, clinical manifestations, and treatment with related nursing care of patients with peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). Learning Outcome 3 Develop a teaching plan for patients with celiac disease. Learning Outcome 4 Analyze the similarities and differences between different types of inflammatory bowel disease. Learning Outcome 5 List the risk factors for developing GERD. Learning Outcome 6 Delineate nursing care for a patient with colon cancer. Learning Outcome 7 Describe the different intestinal tubes and related nursing care for patients with intestinal obstruction. Learning Outcome 8 Discuss the clinical manifestations of the complications of gastric surgery. Learning Outcome 9 Outline the nursing care of a patient with an ileostomy, colostomy, and continent ileostomy. Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
Transcript
[Osborn] chapter 45
Learning Outcomes [Number and Title ]Learning Outcome 1 Describe the different causes of stomatitis and related nursing
care.Learning Outcome 2 Compare and contrast pathophysiology, clinical manifestations,
and treatment with related nursing care of patients with peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD).
Learning Outcome 3 Develop a teaching plan for patients with celiac disease.Learning Outcome 4 Analyze the similarities and differences between different types
of inflammatory bowel disease.Learning Outcome 5 List the risk factors for developing GERD.Learning Outcome 6 Delineate nursing care for a patient with colon cancer.Learning Outcome 7 Describe the different intestinal tubes and related nursing care
for patients with intestinal obstruction.Learning Outcome 8 Discuss the clinical manifestations of the complications of
gastric surgery.Learning Outcome 9 Outline the nursing care of a patient with an ileostomy,
colostomy, and continent ileostomy.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
1. Acyclovir (Zovirax) ointment has been prescribed for a client with oral herpes lesions. The nurse includes the following information when educating the client regarding this medication:
Select all that apply.
1. Adverse effects include vomiting and diarrhea.2. It can reduce the length of the herpes outbreak.3. It is an antibiotic medication.4. Repeated usage of the drug will likely put the client into a permanent remission state.5. It is most effective when administered intravenously.
Correct Answer: 1. Adverse effects include vomiting and diarrhea.2. It can reduce the length of the herpes outbreak.
Rationale: Adverse effects include vomiting and diarrhea. Adverse effects include headache, nausea, vomiting, and diarrhea. It can reduce the length of the herpes outbreak. Acyclovir is used to reduce the severity and length of an outbreak of herpes simplex. It is an antibiotic medication. Acyclovir is an antiviral agent. Repeated usage of the drug will likely put the client into a permanent remission state. Herpes simplex is a viral condition that is not curable, and outbreaks are likely to occur when the client is physically and/or emotionally stressed. It is most affective when administered intravenously. For patients with intact immune systems, oral acyclovir (Zovirax) is generally used.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
2. A client diagnosed with oral cancer has undergone surgery to manage the condition, resulting in scarring both inside and outside of the oral cavity. The nurse developing the plan of care identifies which of the following nursing diagnoses as having highest priority?
1. Nutrition, Imbalanced: more than body requirements, risk for2. Body Image, Disturbed3. Communication: impaired, verbal4. Knowledge Deficient regarding causative factor of disease process
Correct Answer: Nutrition, Imbalanced: more than body requirements, risk for
Rationale: While each of the nursing diagnoses listed is appropriate for the client, nutrition has the highest priority because it affects wound healing and general health. Deferring to Maslow’s hierarchy, the physiological diagnoses would have the highest priority.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
3. A client who has been diagnosed with a bacterial stomatitis affecting his tongue and buccal areas has been reporting oral pain of 6 out of 10. The nurse educates the client regarding the appropriate use of a 2% viscous lidocaine topical medication by encouraging the client to:
1. Use the medication every 3 hours as needed for oral pain control.2. Swallow the medication after swishing it thoroughly in his mouth.3. Refrain from eating or drinking for ½ hour after using the medication.4. Rinse his mouth with an alcohol-based mouthwash prior to using the medication.
Correct Answer: Use the medication every 3 hours as needed for oral pain control.
Rationale: The nurse should inform the patient that the lidocaine may be used every 3 hours as needed. The nurse should ensure that the patient rinses his mouth with the viscous lidocaine, then spits it out, because swallowing the solution may impair the ability to swallow. Using lidocaine just prior to meals may help improve oral intake. Mouthwash containing alcohol should be avoided because it may increase the irritation already present in the mouth.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
4. The client has been diagnosed with gastroesophageal reflux (GERD) that has resulted from a relaxation of the lower esophageal sphincter (LES). When providing instructions to assist with managing the condition, the nurse includes:
Select all that apply.1. Limit last food intake to 4 hours before bedtime.2. Eat largest meal of the day at midday.3. Sleep in a bed with the head elevated 6 to 8 inches.4. Develop a daily exercise routine.5. Include a caffeinated beverage with meals.
Correct Answer:1. Limit last food intake to 4 hours before bedtime.2. Eat largest meal of the day at midday.3. Sleep in a bed with the head elevated 6 to 8 inches.4. Develop a daily exercise routine.
Rationale: Limit last food intake to 4 hours before bedtime. The patient should avoid eating anything within 4 hours of bedtime. Eat largest meal of the day at midday. It is often helpful to eat small frequent meals, with the largest meal at midday. Sleep in a bed with the head elevated 6 to 8 inches. The head of the bed should be elevated. Develop a daily exercise routine. A regular exercise program such as daily walking can promote digestion. Include a caffeinated beverage with meals. Caffeine has been shown to lower LES pressure and so should be avoided.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
5. Discharge teaching for the client with peptic ulcer disease (PUD) is being planned. The nurse includes the following in the educational information provided to the client:
Select all that apply.
1. Good hand-washing practices will minimize the risk of transmission to family.2. Implement strategies to discontinue the use of any tobacco product.3. Check with health care provider before taking over-the-counter medications
containing aspirin.4. Follow a bland, low-fat, high-protein diet with six small meals daily.5. Avoid ingestion of any form of alcoholic beverage.
Correct Answer: 1. Good hand-washing practices will minimize the risk of transmission to family.2. Implement strategies to discontinue the use of any tobacco product.3. Check with health care provider before taking over-the-counter medications
containing aspirin.
Rationale: Good hand-washing practices will minimize the risk of transmission to family. Because H. pylori is found in saliva and feces, increasing the possibility of person-to-person transmission through oral-to-oral and fecal-to-oral routes, good hand hygiene should be encouraged. Implement strategies to discontinue the use of any tobacco product. The rate of healing is slowed and the recurrence rate of PUD is increased in patients who smoke or use tobacco products, so nicotine use should be discouraged. Check with health care provider before taking over-the-counter medications containing aspirin. The patient should be advised not to take NSAIDs or aspirin (or products containing aspirin—e.g., Excedrin, Alka-Seltzer) without first discussing the situation with the healthcare provider. Follow a bland, low-fat, high-protein diet with six small meals daily. There are no specific dietary modifications that an individual with PUD should follow because no food is considered ulcerogenic. Avoid ingestion of any form of alcoholic beverage. Small amounts of alcohol do not cause harm, but large amounts should be avoided.
Cognitive Level: AnalysisNursing Process: PlanningClient Need: Physiological Integrity LO 2
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
6. The nurse is caring for a client diagnosed with achalasia who will be receiving a botulinum toxin (Botox) injection to help improve function of his lower esophageal sphincter (LES) muscle. The nurse includes education to reinforce to the client that this medical intervention will:
1. Usually be effective for 6 to 9 months.2. Require dilation of the esophagus.3. Require general anesthesia.4. Likely result in dysphagia.
Correct Answer: Usually be effective for 6 to 9 months.
Rationale: A less invasive procedure for achalasia is performed with the injection of botulinum toxin (Botox) into the LES through an endoscopic procedure using conscious sedation. The disadvantage of this procedure is that it usually requires repeated treatment every 6 to 9 months. The traditional treatment of achalasia has been the use of esophageal dilation or myotomy. Dysphagia is a result of the condition, not a side effect of the Botox treatment. Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO 2
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
THIS LO HAS 2 QUESTIONS.
7. The nurse recognizes that the symptomology of celiac disease in adults includes:
Select all that apply. 1. Rheumatoid arthritis. 2. Chronic hepatitis.3. Osteoporosis.4. Peptic ulcer disease.5. Chronic constipation.
Rationale: Rheumatoid arthritis. Most adults have signs and symptoms that are unrelated to the GI tract, such as symptoms of rheumatoid arthritis. Chronic hepatitis. Most adults have signs and symptoms that are unrelated to the GI tract, such as symptoms of chronic hepatitis. Osteoporosis. Most adults have signs and symptoms that are unrelated to the GI tract, such as symptoms of osteoporosis. Peptic ulcer disease. PUD is not typically associated with celiac disease. Chronic constipation. Chronic constipation is not typically associated with celiac disease.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
8. The nurse recognizes that the client diagnosed with celiac disease needs further education regarding the disease process when the client states:
1. “I treat myself to a ham and cheese on rye with a light beer once a week.”2. “It’s really difficult to maintain my gluten-free lifestyle.”3. “The only way to truly diagnose this disease it through a biopsy of my small
intestine.”4. “The trouble I’m having with the enamel on my teeth is a result of this disease.”
Correct Answer: “I treat myself to a ham and cheese on rye with a light beer once a week.”
Rationale: The client with celiac disease is incapable of appropriately reacting to ingested gluten and so is placed on a gluten-free diet. Gluten is found in wheat, barley, and rye. Many foods do contain gluten, and so it is difficult to maintain such a diet. A biopsy of the small intestine is the gold standard for diagnosing celiac disease, and dental enamel hypoplasia is a sign often seen in clients with this disease.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
9. A 28-year-old female client is diagnosed with inflammatory disease of the small bowel. When the client describes numerous daily bowel movements but denies the presence of bloody stool, the nurse realizes that this client was most likely diagnosed with:
Rationale: Crohn’s disease is an inflammatory disease of the small bowel that does not present bloody stool as a common characteristic sign. Ulcerative colitis affects the large intestine. Neither chronic diarrhea nor gastroenteritis is necessarily characterized by bloody stool.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
10. A client is hospitalized during an acute exacerbation of symptoms related to Crohn’s. The nurse shows an understanding of the need for bowel rest by discussing with the client that he:
1. Will be receiving total parenteral nutrition (TPN).2. Will be getting only a soft diet until the diarrhea subsides.3. Should select foods that are high in potassium.4. May find a high-calorie, low-fat, high-fiber diet helpful.
Correct Answer: Will be receiving total parenteral nutrition (TPN).
Rationale: During an acute exacerbation of IBD, particularly Crohn’s disease, the patient is allowed no food taken orally. During this period of “bowel rest,” total parenteral nutrition (TPN) is usually prescribed.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
11. The nurse is reviewing the dietary recommendations with a client recovering from an acute episode of diverticular disease. The nurse identifies the following for inclusion in the discussion:
Select all that apply.
1. Incorporating both soluble and insoluble fiber into the daily diet.2. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults.3. Eating oatmeal-based cereals as breakfast and snack foods.4. Avoiding eating fresh grapes because the skins can be problematic.5. Including raisins in the diet as a good source of iron to offset poor iron absorption.
Correct Answer: 1. Incorporating both soluble and insoluble fiber into the daily diet.2. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults.3. Eating oatmeal-based cereals as breakfast and snack foods.4. Avoiding eating fresh grapes because the skins can be problematic.
Rationale: Incorporating both soluble and insoluble fiber into the daily diet. Once the acute phase has passed, dietary recommendations include eating a diet high in both soluble and insoluble fiber. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults. The recommended fiber consumption for the general public of the United States is 25 to 30 grams and should be stressed for the person with diverticular disease. Eating oatmeal-based cereals as breakfast and snack foods. Oatmeal is a high-fiber food recommended for patients with diverticular disease. Avoiding eating fresh grapes because the skins can be problematic. For patients with diverticular disease, foods containing small seeds, nuts, and foods with skins such as grapes are restricted because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis. Including raisins in the diet as a good source of iron to offset poor iron absorption. For patients with diverticular disease, foods containing small seeds, nuts, and foods with skins such as raisins are restricted, because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
THERE ARE 2 QUESTIONS FOR THIS LO.
12. The nurse is preparing information to be included in a community educational presentation regarding gastroesophageal reflux disease (GERD). The decision is made to include the following:
Select all that apply. 1. GERD is more prevalent in adults over the age of 50.2. A substantial number of people self-medicate with OTC medications.3. Control of the symptoms is dependent on a change of diet.4. A reoccurring sore throat may be a symptom of the disease. 5. Vomiting is a common sign of the disease.
Correct Answer: 1. GERD is more prevalent in adults over the age of 50.2. A substantial number of people self-medicate with OTC medications.3. Control of the symptoms is dependent on a change of diet.4. A reoccurring sore throat may be a symptom of the disease.
Rationale: GERD is more prevalent in adults over the age of 50. The incidence of gastroesophageal reflux disease (GERD) increases after age 50, but it can occur at any age and the prevalence is equal across gender, ethnic, and cultural groups. A substantial number of people self-medicate with OTC medications. It is believed that the number of people experiencing reflux may actually be much higher, but because many H2-receptor blockers are available without a prescription, a large number of cases go unreported. Control of the symptoms is dependent on a change of diet. Lifestyle modifications including diet are key in the treatment of GERD. Many patients may have total symptom relief through these efforts alone. A reoccurring sore throat may be a symptom of the disease. Atypical symptoms include asthma or a sore throat. Vomiting is a common sign of the disease. Gastroesophageal reflux is the backward flow of stomach contents (chyme) into the esophagus without associated vomiting.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
13. The nurse is assessing a client who is reporting symptoms similar to those associated with gastroesophageal reflux disease (GERD). The nurse inquires as to whether the client is currently prescribed:
1. Inderal.2. Valium.3. Birth control pills.4. Bronchodilator.5. Nitroglycerine.
Correct Answer: 1. Inderal.2. Valium.3. Birth control pills.4. Bronchodilator.
Rationale: Inderal. The nurse should assess for medications such as beta-adrenergic blockers (Inderal). Valium. The nurse should assess for medications such as diazepam (Valium). Birth control pills. The nurse should assess for medications such as estrogen and progesterone. Bronchodilator. The nurse should assess for medications such as bronchodilators (Theophylline). Nitroglycerine. There is no known connection between nitroglycerine and the symptoms of GERD.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
14. A client with cancer of the rectum is scheduled for surgery and the placement of a permanent ostomy. The nurse includes discussion of which of the following types of ostomies in the client’s presurgical education plan?
Rationale: A sigmoid colostomy is the most common permanent colostomy performed, particularly for cancer of the rectum. The duodenal, double-barrel, and transverse loop colonoscopy are not in the correct area to manage cancer in this location.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
15. A client who has been diagnosed with a form of gastric carcinoma shows concern about the prospects of her adult children having the disease. Which of the following questions asked by the nurse shows an understanding of the disease?
1. “Have any of your children ever been treated for a stomach ulcer?” 2. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon
meats?”3. “Have your children ever been tested for colon cancer?”4. “Do any of your children smoke either cigarettes or cigars?”5. “Are any of your children exhibiting signs of depression or obsessive compulsive
disorder?” Correct Answer:
1. “Have any of your children ever been treated for a stomach ulcer?” 2. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon
meats?”3. “Have your children ever been tested for colon cancer?”
Rationale: “Have any of your children ever been treated for a stomach ulcer?” Helicobacter pylori (H. pylori), a bacterium causing gastritis, is thought to be related to the development of gastric cancer. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon meats?” Nitrates found in smoked meats, bacon, lunch meats, and hot dogs have been linked to the development of gastric cancer as well. “Have your children ever been tested for colon cancer?” Gastric cancer is one of the most common inherited cancer syndromes. “Do any of your children smoke either cigarettes or cigars?” Research has not shown any definitive links between smoking and the occurrence of gastric cancer. “Are any of your children exhibiting signs of depression or obsessive compulsive disorder?” Research has not shown any definitive links between depression or OCD and the occurrence of gastric cancer.
Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
16. To best minimize the client’s risk of developing a postsurgical infection at the site of a permanent colostomy, the nurse:
1. Changes the dressing as ordered by the surgeon.2. Instructs the client in the proper technique for handling hygiene of the colostomy site.3. Administers intravenous antibiotics as prescribed.4. Assesses the client’s understanding of the importance of infection control measures.
Correct Answer: Changes the dressing as ordered by the surgeon.
Rationale: Changing the dressing as ordered by the surgeon will have the greatest impact on keeping the incision clean and dry and helps prevent an infection at the site. Instructing the client regarding proper hygiene techniques is more relevant to long-term prevention of infections. IV antibiotics, while appropriate, will not have the same degree of impact as does good wound care. The client’s understanding of the importance of infection control is more relevant to long-term prevention of infections.
Cognitive Level: AnalysisClient Need: Psychosocial IntegrityNursing Process: Implementation LO 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
17. A nasointestinal tube (NI) has been inserted into a client diagnosed with an intestinal obstruction. Which of the following statements made by the nurse caring for the client indicates a lack of understanding regarding the nursing care required for safe management of this medical intervention?
1. “It’s my habit to irrigate nasointestinal tubes (NI) just prior to administering the client’s sleeping medication.”
2. “The client has been very compliant about remaining on his right side.”3. “The placement of the tubing has been confirmed by x-ray, so now I’ll attach it to low
intermittent suction.”4. “I’ll ambulate the client at least twice before bedtime to help advance the tube.”
Correct Answer: “It’s my habit to irrigate nasointestinal tubes (NI) just prior to administering the client’s sleeping medication.”
Rationale: The tube is not irrigated unless ordered by the health care provider. Once inserted into the stomach, position the patient on his right side. The health care provider may order the tube to be advanced 2 to 4 inches at a time or to let gravity move the tube into the small intestine. Movement of the patient, either ambulation or changing positions in bed, will assist the forward movement of the tube. Low intermittent suction may be ordered once placement is confirmed by x-ray.
Rationale: In a strangulated bowel obstruction, there is an interruption of blood flow, both venous and arterial, by mechanical means, which can result from surgical adhesions. There is no research to support a genetic link or an increased risk related to high blood cholesterol levels. Impairment of arterial blood flow resulting from the strangulation leads to ischemic infarctions.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
19. A client is being assessed for a possible bowel obstruction. The nurse provides the client with information regarding diagnostics to confirm the presence of an obstruction that include:
Select all that apply.1. An abdominal x-ray series. 2. A CT scan of the abdomen.3. CBC with differential. 4. Serum osmolality. 5. Barium swallow.
Correct Answer: 1. An abdominal x-ray series. 2. A CT scan of the abdomen.
Rationale: An abdominal x-ray series. Confirmation of the diagnosis can be made by x-rays. A CT scan of the abdomen. Confirmation of the diagnosis can be made by CT scan. CBC with differential. The laboratory tests, although not diagnostic, will be done to determine the presence of infection and/or dehydration. Serum osmolality. The laboratory tests, although not diagnostic, will be done to determine the presence of infection and/or dehydration. Barium swallow. A barium swallow is contraindicated because of the possibility of intestinal perforation or a worsening of the obstruction.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
20. During a follow-up visit 4 weeks after gastric resection surgery, a client reports experiencing cramping, nausea, and diarrhea within 10 minutes after eating. The nurse suspects that the client is experience “dumping syndrome” and suggests that he:
Select all that apply.
1. Increase the protein in his diet.2. Lie down for 30 minutes immediately after eating.3. Eat frequent, small meals.4. Reduce the amount of carbohydrates eaten daily.5. Drink a glass of water prior to each meal.
Correct Answer:1. Increase the protein in his diet.2. Lie down for 30 minutes immediately after eating.3. Eat frequent, small meals.4. Reduce the amount of carbohydrates eaten daily.
Rationale: Increase the protein in his diet. Increasing the amount of protein and fat in the diet will help slow the transit time. Lie down for 30 minutes immediately after eating. The patient should be instructed to lie down for 30 to 60 minutes after eating to slow transit time. Eat frequent, small meals. The symptoms can be managed by eating small, more frequent meals. Reduce the amount of carbohydrates eaten daily. Carbohydrates should be reduced in order to help slow the transit time. Drink a glass of water prior to each meal. Drinking before eating actually might intensify the problem.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
21. A client who has had gastric surgery that affected the effectiveness of his alimentary system will be fed via a gastrostomy tube upon his discharge to home. The nurse recognizes that the primary reason for this means of nutrition is that it is:
1. Less likely to produce side effects than parenteral nutrition.2. Less invasive than a jejunostomy tube.3. More cost effective than nasogastric feeding.4. More supportive of the specialized diet the client will require.
Correct Answer: Less likely to produce side effects than parenteral nutrition.
Rationale: The purpose of a gastrostomy tube is to provide complete nutrition through the alimentary system. It is safer and has fewer side effects than total parenteral nutrition (TPN), particularly when the patient is to have feedings at home. The gastrostomy tube is as invasive as the jejunostomy tube. It is not necessarily more cost effective than nasogastric feeding, nor is it more appropriate for specialized feeding needs. Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological Integrity LO 8
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
22. A client diagnosed with peptic ulcer disease (PUD) asks the nurse whether it is likely that surgery will be required to successfully treat this condition. The nurse shows an understanding of this disease process when responding:
1. “The administration of the appropriate medications makes surgery rarely necessary.” 2. “Surgery is required in about 50% of the cases.”3. “Surgery has a higher success rate than medication therapy alone.”4. “If you take your medications and follow the prescribed diet, surgery isn’t usually needed.”
Correct Answer: “The administration of the appropriate medications makes surgery rarely necessary.”
Rationale: Fortunately, with the discovery of H. pylori infection as the major cause of peptic ulcers, and the development of medications to eradicate this organism, surgery is rarely necessary. The success rate of pharmacologic intervention is to eradicate H. pylori is 75% to 90%. There are no specific dietary modifications for PUD.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
23. The nurse tells the client that his newly created permanent ileostomy:
1. Will initially produce dark green fecal matter.2. Will require additional surgery in 2 to 3 months.3. Was necessary when his condition required a gastroduodenostomy (Billroth I).4. Should not produce any bloody discharge.
Correct Answer: Will initially produce dark green fecal matter.
Rationale: Initially the ileostomy will produce effluent that is dark green and viscous, gradually turning yellow-brown. A permanent ileostomy does not generally require follow-up surgery. Immediately postoperative there may be small amounts of blood. An ileostomy is not the outcome of a gastroduodenostomy (Billroth I).
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
24. The nurse’s instructions to a client with a newly created Koch ileostomy (continent ileostomy) include:
Select all that apply.
1. The surgery involved manipulating a portion of the terminal ileum.2. A nipple valve was created to control the flow of fecal matter.3. The stoma should appear pink and moist.4. Fecal matter will be removed by a catheter inserted through the stoma.5. The stoma will be reversed when the bowels have had the time to heal.
Correct Answer: 1. The surgery involved manipulating a portion of the terminal ileum.2. A nipple valve was created to control the flow of fecal matter.3. The stoma should appear pink and moist.4. Fecal matter will be removed by a catheter inserted through the stoma.
Rationale: The surgery involved manipulating a portion of the terminal ileum. A continent ileostomy, also known as Kock ileostomy or Kock pouch, involves the terminal ileum being folded back on itself and the inner wall removed, thereby forming a reservoir and a nipple valve. The end is then brought through the abdominal wall to form a stoma. A nipple valve was created to control the flow of fecal matter. The nipple valve prevents leaking of fecal contents through the stoma. The stoma should appear pink and moist. The stoma should appear pink and moist. Fecal matter will be removed by a catheter inserted through the stoma. The reservoir is emptied by a catheter inserted through the stoma. The stoma will be reversed when the bowels have had the time to heal. This is not generally a reversible, temporary procedure.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
25. Good skin and stomal integrity is a goal included in the care plan of a client with a colostomy. The evaluation parameters best suited for this goal includes:
Select all that apply.
1. Stoma pink and moist.2. No excoriation noted on skin surrounding stoma.3. Client shows understanding of importance of preventing fecal leakage.4. Client demonstrates ability to apply collecting appliance properly.5. Stomal area is free of pain.
Correct Answer: 1. Stoma pink and moist.2. No excoriation noted on skin surrounding stoma.
Rationale: Stoma pink and moist. Evaluation parameters for the stated goal are: Stoma pink and moist and Skin surrounding stoma pink, no excoriation. No excoriation noted on skin surrounding stoma. Evaluation parameters for the stated goal are: Stoma pink and moist and Skin surrounding stoma pink, no excoriation. Client shows understanding of importance of preventing fecal leakage. Evaluation parameters for the stated goal are: Stoma pink and moist and Skin surrounding stoma pink, no excoriation. Client demonstrates ability to apply collecting appliance properly. This is not related to skin integrity but rather client understanding of the condition and pain. Stomal area is free of pain. This is not related to skin integrity but rather client understanding of the condition and pain.
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