Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is developing a plan of care for a client who has a new ileal conduit. Which of the following should the nurse include as risks for the client? (Select all that apply.)
A. Anxiety
Choice A reason: A new ileal conduit is a permanent life change that requires the client to learn complex self-care skills. The uncertainty regarding stoma management, fear of appliance leakage in public, and the lifestyle adjustments required often lead to significant anxiety. The nurse must address these psychological stressors during the initial postoperative period to promote successful adaptation.
B. Impaired skin integrity
Choice B reason: The continuous drainage of urine from the stoma creates a high risk for peristomal skin breakdown. Urine is caustic to the skin, and moisture trapped under the skin barrier can lead to maceration, dermatitis, or fungal infections. Maintaining a secure, well-fitted appliance and assessing the skin frequently are essential nursing interventions for this risk.
C. Infection
Choice C reason: Surgical creation of an ileal conduit involves bowel resection and ureteral implantation, increasing the risk for peritonitis or wound infection. Furthermore, since the conduit is a direct pathway to the kidneys without a sphincter, the client is at lifelong risk for ascending urinary tract infections or pyelonephritis requiring vigilant monitoring.
D. Fluid volume deficit
Choice D reason: While postoperative patients require fluid monitoring, an ileal conduit does not typically cause a chronic fluid volume deficit. Unlike an ileostomy, where significant water and electrolytes are lost through liquid stool, the ileal conduit simply transports urine. Unless there is excessive surgical bleeding or unrelated dehydration, this is not a primary risk.
E. Disturbed body image
Choice E reason: The permanent diversion of urine to an external pouch on the abdomen significantly alters the client's physical appearance and "normal" elimination process. Concerns regarding sexual function, clothing choices, and the presence of a stoma frequently lead to a disturbed body image, necessitating supportive counseling and referral to an ostomy nurse.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam Midterm Rn 36 1125. Take the full exam now
Full Explanation
Choice A reason: A new ileal conduit is a permanent life change that requires the client to learn complex self-care skills. The uncertainty regarding stoma management, fear of appliance leakage in public, and the lifestyle adjustments required often lead to significant anxiety. The nurse must address these psychological stressors during the initial postoperative period to promote successful adaptation.
Choice B reason: The continuous drainage of urine from the stoma creates a high risk for peristomal skin breakdown. Urine is caustic to the skin, and moisture trapped under the skin barrier can lead to maceration, dermatitis, or fungal infections. Maintaining a secure, well-fitted appliance and assessing the skin frequently are essential nursing interventions for this risk.
Choice C reason: Surgical creation of an ileal conduit involves bowel resection and ureteral implantation, increasing the risk for peritonitis or wound infection. Furthermore, since the conduit is a direct pathway to the kidneys without a sphincter, the client is at lifelong risk for ascending urinary tract infections or pyelonephritis requiring vigilant monitoring.
Choice D reason: While postoperative patients require fluid monitoring, an ileal conduit does not typically cause a chronic fluid volume deficit. Unlike an ileostomy, where significant water and electrolytes are lost through liquid stool, the ileal conduit simply transports urine. Unless there is excessive surgical bleeding or unrelated dehydration, this is not a primary risk.
Choice E reason: The permanent diversion of urine to an external pouch on the abdomen significantly alters the client's physical appearance and "normal" elimination process. Concerns regarding sexual function, clothing choices, and the presence of a stoma frequently lead to a disturbed body image, necessitating supportive counseling and referral to an ostomy nurse.
Similar Questions
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as modifiable risk factors for this disorder? (Select all that apply.)
A. Hypertension
Hypertension is a modifiable risk factor for atherosclerosis. Managing blood pressure through lifestyle changes and medication can reduce the risk of developing atherosclerosis.
B. Hypercholesterolemia
Hypercholesterolemia, or high cholesterol, is another modifiable risk factor. Dietary adjustments, physical activity, and medications can help manage cholesterol levels.
C. Genetic predisposition
Genetic predisposition is not a modifiable risk factor. It is an inherent risk that cannot be changed, but awareness can prompt early monitoring and intervention.
D. Obesity
Obesity is a modifiable risk factor for atherosclerosis. Weight loss through diet and exercise can significantly reduce the risk.
E. Smoking
Smoking is a significant modifiable risk factor for atherosclerosis. Quitting smoking can greatly reduce the risk of developing this condition.
Full Explanation
Choice A rationale
Hypertension is a modifiable risk factor for atherosclerosis. Managing blood pressure through lifestyle changes and medication can reduce the risk of developing atherosclerosis.
Choice B rationale
Hypercholesterolemia, or high cholesterol, is another modifiable risk factor. Dietary adjustments, physical activity, and medications can help manage cholesterol levels.
Choice C rationale
Genetic predisposition is not a modifiable risk factor. It is an inherent risk that cannot be changed, but awareness can prompt early monitoring and intervention.
Choice D rationale
Obesity is a modifiable risk factor for atherosclerosis. Weight loss through diet and exercise can significantly reduce the risk.
Choice E rationale
Smoking is a significant modifiable risk factor for atherosclerosis. Quitting smoking can greatly reduce the risk of developing this condition.
A nurse is giving a presentation about preventing deep vein thrombosis (DVT). Which of the following should the nurse include as risk factors for this disorder? (Select all that apply.)
A. Immobility
Immobility is a significant risk factor for DVT as it can lead to stagnation of blood in the veins, increasing the risk of clot formation.
B. High calcium intake
High calcium intake is not typically associated with an increased risk of DVT. Instead, factors like immobility, certain medications, and medical conditions are more influential.
C. Oral contraceptive use
Oral contraceptive use, especially those containing estrogen, can increase the risk of DVT due to their effect on blood clotting mechanisms.
D. BMI of 20
A BMI of 20 is considered within the normal range and is not a risk factor for DVT. Obesity, which is a BMI of 30 or higher, would be a risk factor.
E. Hypertension
Hypertension itself is not a direct risk factor for DVT. However, it can be associated with other health conditions that may increase the risk of thrombosis.
Full Explanation
Choice A rationale
Immobility is a significant risk factor for DVT as it can lead to stagnation of blood in the veins, increasing the risk of clot formation.
Choice B rationale
High calcium intake is not typically associated with an increased risk of DVT. Instead, factors like immobility, certain medications, and medical conditions are more influential.
Choice C rationale
Oral contraceptive use, especially those containing estrogen, can increase the risk of DVT due to their effect on blood clotting mechanisms.
Choice D rationale
A BMI of 20 is considered within the normal range and is not a risk factor for DVT. Obesity, which is a BMI of 30 or higher, would be a risk factor.
Choice E rationale
Hypertension itself is not a direct risk factor for DVT. However, it can be associated with other health conditions that may increase the risk of thrombosis.
A nurse is educating the public at a health fair about colorectal cancer. Which of the following risk factors increase the risk of developing colorectal cancer? (Select all that apply.)
A. Smoking
Smoking is a well-established risk factor for colorectal cancer. The carcinogens in tobacco smoke can lead to the formation of cancerous cells in the colon and rectum.
B. Obesity
Obesity increases the risk of colorectal cancer, possibly due to chronic low-level inflammation associated with excess body fat, which can contribute to cancer development.
C. Limiting alcohol intake to less than four drinks per week
Limiting alcohol intake to less than four drinks per week is actually a protective measure against colorectal cancer, not a risk factor.
D. More than seven servings of red meat per week
A high intake of red meat, particularly more than seven servings per week, has been linked to an increased risk of colorectal cancer due to compounds formed during digestion that can damage the lining of the colon and rectum.
E. A diet high in fruits, vegetables, and grains
A diet high in fruits, vegetables, and grains is generally considered protective against colorectal cancer due to the fiber and nutrients they provide, not a risk factor.
Full Explanation
Choice A rationale
Smoking is a well-established risk factor for colorectal cancer. The carcinogens in tobacco smoke can lead to the formation of cancerous cells in the colon and rectum.
Choice B rationale
Obesity increases the risk of colorectal cancer, possibly due to chronic low-level inflammation associated with excess body fat, which can contribute to cancer development.
Choice C rationale
Limiting alcohol intake to less than four drinks per week is actually a protective measure against colorectal cancer, not a risk factor.
Choice D rationale
A high intake of red meat, particularly more than seven servings per week, has been linked to an increased risk of colorectal cancer due to compounds formed during digestion that can damage the lining of the colon and rectum.
Choice E rationale
A diet high in fruits, vegetables, and grains is generally considered protective against colorectal cancer due to the fiber and nutrients they provide, not a risk factor.
