the client who has undergone creation of a colostomy has a nursing diagnosis of disturbed body image the nurse would evaluate that the client is makin
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Nursing Elites

ATI RN

ATI Gastrointestinal System Quizlet

1. The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

Correct answer: D

Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.

2. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?

Correct answer: C

Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).

3. The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

Correct answer: D

Rationale: Aspiration of gastric contents can lead to a chronic cough in clients with GERD.

4. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

Correct answer: A

Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.

5. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

Similar Questions

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The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?
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