A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?
The stoma appears dark purple in color.
The colostomy has had no output.
The client refuses to look at the colostomy.
The client reports a pain level of 6 on a scale from 0 to 10
The Correct Answer is A
A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
- Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
- Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
- Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
- Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
- Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.
Correct Answer is A
Explanation
A. Shows perfectionism. Clients with obsessive-compulsive personality disorder (OCPD) are characterized by perfectionism, a preoccupation with orderliness, control, and rules, and a need for mental and interpersonal control, often at the expense of flexibility and efficiency.
B. Takes advantage of others. This behavior is more typical of antisocial personality disorder, not OCPD. Clients with OCPD tend to be highly conscientious, not manipulative or exploitative.
C. Irritability. While clients with OCPD may become frustrated or anxious if things are not done their way, chronic irritability is not a hallmark feature of the disorder.
D. Impulsivity. Impulsivity is more commonly associated with borderline or antisocial personality disorders. In contrast, clients with OCPD are typically rigid, cautious, and rule-bound.
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