Nursing Elites

1. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

• A. Sunken and hidden stoma
• B. Dark- and bluish-colored stoma
• C. Narrowed and flattened stoma
• D. Protruding stoma

Correct answer: D

Rationale: A protruding stoma is indicative of stoma prolapse, which occurs when the bowel protrudes excessively through the stoma.

2. The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?

• A. The family's ability to take care of the client's special diet needs
• B. The family's expectation that the client will resume responsibilities and role-related activities
• C. Emotional support from the family
• D. The family's ability to understand the ups and downs of the illness

Correct answer: C

Rationale: Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client.

3. A 30-year old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently?

• A. Milk and dairy products
• B. Protein-containing foods
• C. Cereal grains (except rice and corn)
• D. Carbohydrates

Correct answer: C

Rationale: Gluten-induced enteropathy, or celiac disease, requires the elimination of gluten-containing grains like wheat, barley, and rye. Dairy, proteins, and carbohydrates are not excluded unless the client has specific intolerances.

4. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.

5. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

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