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Author Question: The nurse is visiting the patient for the first time this shift. She introduces herself and asks the ... (Read 72 times)

awywial

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on: Jul 24, 2018
The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition.
 
  While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation
  b. Percussion
  c. Inspection
  d. Auscultation

Question 2

In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential?
 
  a. Place a pouch over the newly created stoma.
  b. Place a dressing over the stoma.
  c. Wait several days before placing a pouch.
  d. Prepare several pouches in advance.


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Kimmy

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Reply #1 on: Jul 24, 2018
Answer to Question 1

C
Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body.

Answer to Question 2

A
Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odor. Dressings would obstruct the opening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching system to meet the changing size of the stoma and the changes in body contours.


awywial

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Reply #2 on: Jul 24, 2018
Thank you!


Kimmy

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Reply #3 on: Jul 24, 2018
Always glad to help...


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