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. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following instructions do you include?

Correct answer: C

Rationale: Advise the patient to lose weight if obese to reduce the risk of complications after herniorrhaphy.

3. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

4. The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:

Correct answer: D

Rationale: A pyloroplasty involves making an incision in the pylorus (the opening from the stomach to the duodenum) and then resuturing it to relax the muscle and enlarge the opening.

5. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

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