ETSU NRSE 2350 PCC1 Exam 2 Questions With Complete
Solutions
Describe a bowel training program. Correct Answer -
Assessing the normal elimination pattern and recording times
when the patient is incontinent
-Incorporating principles of gerontological nursing when
providing bowel retraining programs for the older adult
-Choosing a time in the patient's pattern to initiate defecation
control measures
-Giving stool softeners orally every day or a cathartic
suppository at least half an hour before the selected defecation
time (lower colon needs to be free of stool so suppository
contacts intestinal mucosa)
-Offering a hot drink (hot tea) or fruit juice (prune juice) (or
whatever fluids normally stimulate peristalsis for the patient)
before the defecation time
-Helping the patient to the toilet at the designated time
-Avoiding medications such as opioids that increase constipation
Providing privacy and setting a time limit for defecation (15 to
20 minutes)
-Instructing the patient to lean forward at the hips while sitting
on the toilet, apply manual pressure with the hands over the
abdomen, and bear down but not strain to stimulate colon
emptying
-Not criticizing or conveying frustration if the patient is unable
to defecate
-Maintaining normal exercise within the patient's physical
ability]
,Describe abdominal changes across the life span. Correct
Answer -*Infant*: Protuberant abdomen, Umbilical stump,
Abdominal respirations
-*Child >7 yrs*: Lordosis - protuberant when standing, Used
objective finding to assess abdominal pain, Self-image
-*Ageing Adult*: Increased subcutaneous fat, Less abdominal
tone , Thin musculature makes palpation easy
Describe condom catheter care. Correct Answer -Assess for
erythema, rash, or open skin
-Assess for swelling, discoloration, or discomfort
-Urinary patency and urine characteristics
Describe enema administration. Correct Answer -Wear gloves
-If pt reports discomfort lower fluid bag
-Warm enema solution before administration
-Position in Sims position
-Lubricate the nozzle
-Insert 3-4"
Describe ostomy care and assessment. Correct Answer -
Patients with temporary or permanent bowel diversions have
unique elimination needs. An individual with an ostomy wears a
pouch or appliance to collect effluent—stool discharged from
the stoma.
-Skin breakdown occurs after repeated exposure to liquid stool.
The patient needs to use meticulous skin care to prevent liquid
stool from irritating the skin around the stoma.
[Irrigating a colostomy is discussed on the next slide.]
, -An ostomy requires a pouch to collect fecal material. A person
wearing a pouch needs to feel secure enough to participate in
any activity.
-Proper selection and use of an ostomy pouching system are
necessary to prevent damage to the skin around the stoma.
Many pouching systems are available. To ensure that a pouch
fits well and meets the patient's needs, consider the location of
the ostomy, type and size of the stoma, type and amount of
ostomy drainage, size and contour of the abdomen, condition of
the skin around the stoma, physical activities of the patient,
patient's personal preference, age and dexterity, and cost of
equipment.
-A wound ostomy continence nurse (WOCN) is specially
educated to care for ostomy patients; the WOCN collaborates
with staff nurses to make sure that the patient uses the correct
pouching system, especially when the patient is ill or is
experiencing health changes or problems with the ostomy.
-A pouching system consists of a pouch and a skin barrier.
-Assess the stoma color. *A normal stoma is bright pink or brick
red*. Notify the health care provider if the stoma is blue, brown,
or black, which indicates circulation problems to the stoma. You
need to measure the stoma size carefully when selecting and
cutting out the opening on the wafer skin barrier. Too tight of an
opening constricts the stoma and causes irritation and necrosis.
Subtle stoma changes occur over time
Describe subjective data during neurological assessment.
Correct Answer -*Headache*: Any unusually frequent or
severe headaches?
-*Head injury*: Ever had any head injury? Please describe.
Solutions
Describe a bowel training program. Correct Answer -
Assessing the normal elimination pattern and recording times
when the patient is incontinent
-Incorporating principles of gerontological nursing when
providing bowel retraining programs for the older adult
-Choosing a time in the patient's pattern to initiate defecation
control measures
-Giving stool softeners orally every day or a cathartic
suppository at least half an hour before the selected defecation
time (lower colon needs to be free of stool so suppository
contacts intestinal mucosa)
-Offering a hot drink (hot tea) or fruit juice (prune juice) (or
whatever fluids normally stimulate peristalsis for the patient)
before the defecation time
-Helping the patient to the toilet at the designated time
-Avoiding medications such as opioids that increase constipation
Providing privacy and setting a time limit for defecation (15 to
20 minutes)
-Instructing the patient to lean forward at the hips while sitting
on the toilet, apply manual pressure with the hands over the
abdomen, and bear down but not strain to stimulate colon
emptying
-Not criticizing or conveying frustration if the patient is unable
to defecate
-Maintaining normal exercise within the patient's physical
ability]
,Describe abdominal changes across the life span. Correct
Answer -*Infant*: Protuberant abdomen, Umbilical stump,
Abdominal respirations
-*Child >7 yrs*: Lordosis - protuberant when standing, Used
objective finding to assess abdominal pain, Self-image
-*Ageing Adult*: Increased subcutaneous fat, Less abdominal
tone , Thin musculature makes palpation easy
Describe condom catheter care. Correct Answer -Assess for
erythema, rash, or open skin
-Assess for swelling, discoloration, or discomfort
-Urinary patency and urine characteristics
Describe enema administration. Correct Answer -Wear gloves
-If pt reports discomfort lower fluid bag
-Warm enema solution before administration
-Position in Sims position
-Lubricate the nozzle
-Insert 3-4"
Describe ostomy care and assessment. Correct Answer -
Patients with temporary or permanent bowel diversions have
unique elimination needs. An individual with an ostomy wears a
pouch or appliance to collect effluent—stool discharged from
the stoma.
-Skin breakdown occurs after repeated exposure to liquid stool.
The patient needs to use meticulous skin care to prevent liquid
stool from irritating the skin around the stoma.
[Irrigating a colostomy is discussed on the next slide.]
, -An ostomy requires a pouch to collect fecal material. A person
wearing a pouch needs to feel secure enough to participate in
any activity.
-Proper selection and use of an ostomy pouching system are
necessary to prevent damage to the skin around the stoma.
Many pouching systems are available. To ensure that a pouch
fits well and meets the patient's needs, consider the location of
the ostomy, type and size of the stoma, type and amount of
ostomy drainage, size and contour of the abdomen, condition of
the skin around the stoma, physical activities of the patient,
patient's personal preference, age and dexterity, and cost of
equipment.
-A wound ostomy continence nurse (WOCN) is specially
educated to care for ostomy patients; the WOCN collaborates
with staff nurses to make sure that the patient uses the correct
pouching system, especially when the patient is ill or is
experiencing health changes or problems with the ostomy.
-A pouching system consists of a pouch and a skin barrier.
-Assess the stoma color. *A normal stoma is bright pink or brick
red*. Notify the health care provider if the stoma is blue, brown,
or black, which indicates circulation problems to the stoma. You
need to measure the stoma size carefully when selecting and
cutting out the opening on the wafer skin barrier. Too tight of an
opening constricts the stoma and causes irritation and necrosis.
Subtle stoma changes occur over time
Describe subjective data during neurological assessment.
Correct Answer -*Headache*: Any unusually frequent or
severe headaches?
-*Head injury*: Ever had any head injury? Please describe.
