A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Denies feelings of sadness about the ostomy

Participates in performing ostomy care

Prefers not to look at the stoma site

Accepts that sexual activity will decrease

Answer and Explanation

The Correct Answer is B

A. Denies feelings of sadness about the ostomy: Denial of sadness may indicate avoidance or suppression of emotions rather than true acceptance. Clients may still be struggling internally despite outwardly denying negative feelings, so this alone is not a reliable indicator of acceptance.

B. Participates in performing ostomy care: Actively engaging in self-care demonstrates adaptation to the altered body image and a willingness to manage the ostomy. Participation reflects acceptance, independence, and confidence in coping with lifestyle changes associated with the stoma.

C. Prefers not to look at the stoma site: Avoiding the stoma indicates discomfort or distress with body changes and suggests the client has not fully accepted their new body image. This behavior is more indicative of denial or anxiety rather than adaptation.

D. Accepts that sexual activity will decrease: Believing sexual activity will decrease may reflect misconceptions or fear rather than true acceptance. Acceptance of altered body image involves active coping and integration into daily life, not just resignation to perceived limitations.

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Correct Answer is C

Explanation

A. "I should limit my conversation with the client while wearing my mask.": Limiting unnecessary talking reduces the risk of mask contamination and prevents droplets from escaping around the mask. This reflects safe practice when working close to the airway during suctioning.

B. "After completing the suctioning, I should remove my gloves.": Gloves are removed first because they are the most contaminated item after suctioning. Taking them off immediately helps prevent cross-contamination and maintains correct PPE removal order. This shows appropriate understanding of PPE technique.

C. "I will need to wear an N95 respiratory mask while suctioning the client.": An N95 mask is not required for community-acquired pneumonia because it is transmitted by droplets, not airborne particles. A surgical mask provides adequate protection for droplet precautions. This statement shows misunderstanding and indicates a need for further teaching.

D. "I will pull the glove cuff over the wrist of the gown.": This technique prevents skin exposure and creates a proper seal between the glove and gown. It reduces the risk of contamination during suctioning procedures.

A. Noticeable stool odor B. Purplish stoma C. Slight bleeding around the stoma D. Soft, unformed stools

Correct Answer is B

Explanation

A. Noticeable stool odor: Some odor is expected with normal colostomy output and can be managed with proper pouching and hygiene. This finding alone does not indicate a complication and typically does not require provider notification.

B. Purplish stoma: A purplish or dark-colored stoma may indicate compromised blood flow, ischemia, or necrosis, which is a medical emergency. Prompt reporting allows immediate assessment and intervention to prevent tissue death or further complications.

C. Slight bleeding around the stoma: Minor bleeding from the stoma or the surrounding skin can occur due to irritation or minor trauma during pouch changes. This is usually not urgent but should be monitored for worsening signs.

D. Soft, unformed stools: Variations in stool consistency are common after colostomy surgery, especially with diet changes. Soft stools are typically expected and do not signal a complication that requires immediate provider notification.

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A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing teaching about ostomy care with a client who has a new colostomy. Which of the following findings should the nurse instruct the client to report to the provider?

Correct Answer is B

Explanation

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