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Perioperative ISB Case Study quiz
1 points
(Ignatavicius, 2022)
A 45-year-old male client had a partial Which client statements require a follow-
colectomy with descending colostomy up assessment by the nurse? Select all that
secondary to colon cancer 3 days ago. apply.
The client had a history of colorectal
polyps and ulcerative colitis and a body "My wife plans on bringing the kids to
mass index (BMI) of 42. He is married and see me today. Hopefully they won't
has three children, works as a computer bother anyone."
programmer, and was independent prior "There is finally some stool in my
to surgery. The shift report indicates that colostomy bag. I think that's a good
the client had a difficult recovery after
sign, right?"
surgery and has been on bedrest since
admission. "My right leg seems skinnier
than my left leg, which is warm
and swollen."
"I didn't sleep well last night. The tech
turned on the lights at 4:00 am to take
my blood."
"The tech said my vital signs
are back to normal. I feel like I
can get out of bed today."
Selected Answer - Incorrect
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, "I have pain in my left calf. It's
tolerable but I would rate it as a
4 on a scale of 0 to 10."
"The incision looks better, but the
ostomy is red and appears a little
moist."
Feedback
Based on answering incorrectly
The nurse would follow-up with the
client's report of pain. although the
client indicates that the pain is
'tolerable', the nurse will want to
perform a more detailed assessment to
determine pain location, quality,
severity, timing, radiation, precipitating
events, and relieving factors. The nurse
would also want to perform a follow-up
assessmet on the client's lower
extremities based on the client's report
that one leg is swollen. Unilateral
edema has several causes, and the
nurse must perform a focused
assessment to evaluate potential
conditions. None of the other client
comments require a follow-up
assessment. The nurse may want to
respond to the other comments and
reinforce teaching, but a focused
assessment is not required.
2 points
The nurse is concerned that the client may
had a blood clot and performs an
assessment of the left lower extremity
(LLE). For each finding below, identify if the
finding is consistent with the present of an
arterial thrombus or a deep vein
thrombosis (DVT).
Arterial Thrombus
Capillary
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