A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?
Encourage the client and partner to avoid expressing negative feelings about the colostomy.
Suggest the client join a support group for people who have colostomies.
Instruct the client's partner to assume care of the colostomy for the client.
Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.
The Correct Answer is B
Rationale:
A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.
B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.
C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.
D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.
B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.
C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.
D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.
Correct Answer is D
Explanation
Rationale:
A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.
B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.
C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.
D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.
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