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 hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

Correct answer: D

Rationale: Rebound tenderness is a sign of peritonitis, a serious complication that needs to be reported to the physician immediately.

3. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

Correct answer: C

Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.

4. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:

Correct answer: A

Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.

5. The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?

Correct answer: C

Rationale: The client should limit fat in the diet. The client also should take in small meals, which also will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

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