A nurse in a provider's office is collecting data from a client who is 1 month postoperative following an ileostomy. Which of the following statements by the client indicates the client is in the acceptance stage of grieving?
"I have purchased a stoma cap I can use when needed."
"I have my partner empty my pouch for me every morning."
"I am embarrassed by the odor that comes from my ileostomy."
"I miss going to my church meetings because of this ostomy."
The Correct Answer is A
Choice A reason: Purchasing a stoma cap that can cover and conceal the ileostomy when not in use indicates that the client is in the acceptance stage of grieving, as it shows that they have adapted to their new condition and are able to resume their normal activities and social interactions.
Choice B reason: Having their partner empty their pouch for them every morning indicates that the client is in the denial stage of grieving, as it shows that they are avoiding or rejecting their new condition and are dependent on others for their care.
Choice C reason: Being embarrassed by the odor that comes from their ileostomy indicates that the client is in the depression stage of grieving, as it shows that they have low self-esteem and negative feelings about their new condition and its impact on their quality of life.
Choice D reason: Missing going to their church meetings because of their ostomy indicates that the client is in the anger stage of grieving, as it shows that they have resentment and frustration about their new condition and its interference with their previous routines and values.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.
Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.
Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.
Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.
Correct Answer is B
Explanation
Choice A: This is incorrect. The nurse should don clean gloves before removing the dressing, and then change to sterile gloves before applying the new dressing.
Choice B: This is correct. The nurse should offer the client pain medication before the procedure, as changing a dressing for a stage III pressure ulcer can be very painful.
Choice C: This is incorrect. The nurse should prepare the sterile dressing supplies just before the dressing change, not 30 min before, to prevent contamination.
Choice D: This is incorrect. The nurse should not disinfect the wound bed with alcohol, as this can damage the healthy tissue and delay healing. The nurse should use a saline solution or an antiseptic solution as prescribed.
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