A nurse is assessing a client's ability to adapt to a new colostomy. Which of the following client statements indicates to the nurse the client is adapting?

"I will need to stay away from others because they will be able to smell this as much as I can.".

"My stoma is starting to look like a strawberry with a hole in it.".

"My partner is in charge of emptying the contents of my bag.".

"I will have to get used to eliminating many foods from my diet.".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.

Choice B rationale:

Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.

Choice C rationale:

This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.

The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.

Choice D rationale:

Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.

Choice B rationale:

Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.

Choice C rationale:

Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.

Choice D rationale:

Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.

Choice E rationale:

Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.

A. PT 12 seconds. B. aPTT 75 seconds. C. INR 1.1. D. Platelets 200,000/mm².

Correct Answer is B

Explanation

Choice A rationale:

A PT (Prothrombin Time) of 12 seconds is not indicative of the effectiveness of heparin therapy for a pulmonary embolism. PT measures the extrinsic pathway of the coagulation cascade, and it is more relevant to monitor in patients on warfarin therapy.

Choice B rationale:

The aPTT (Activated Partial Thromboplastin Time) of 75 seconds is the correct choice as it reflects the effectiveness of unfractionated heparin therapy. Heparin works by inhibiting clotting factors in the intrinsic pathway, and the aPTT is used to monitor heparin's anticoagulant effect. The normal range for aPTT is typically 25-35 seconds.

Choice C rationale:

An INR (International Normalized Ratio) of 1.1 is not the appropriate parameter to assess the effectiveness of heparin therapy. INR is primarily used to monitor the effectiveness of oral anticoagulants like warfarin, not heparin.

Choice D rationale:

The platelet count of 200,000/mm² is not a suitable parameter to evaluate the effectiveness of heparin therapy. Platelet count is important for assessing the risk of bleeding or clotting disorders but does not directly measure the impact of heparin on clotting factors.

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A nurse is assessing a client's ability to adapt to a new colostomy. Which of the following client statements indicates to the nurse the client is adapting?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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