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?

Choice A rationale

Ambulation can stimulate peristalsis and promote bowel movements. However, ambulation is not the priority when the client reports severe abdominal pain rated 7/10 and vomiting. These symptoms could indicate a potential obstruction or other complications, and further evaluation is essential before initiating physical activity to avoid exacerbating the condition.

Choice B rationale

Encouraging oral intake is important to prevent dehydration, particularly if the client has been vomiting. However, this is not the first intervention, as assessing the underlying cause of the symptoms takes precedence. Increasing oral intake without addressing potential gastrointestinal obstruction may worsen the client's condition.

Choice C rationale

Administering antiemetics can provide symptom relief for nausea and vomiting. However, this intervention addresses a symptom rather than identifying the underlying cause of the client's abdominal pain and vomiting. Further evaluation by a provider is necessary before symptomatic management.

Choice D rationale

Notifying the provider allows for further evaluation and timely diagnosis of the cause of the abdominal pain and vomiting, which could indicate serious conditions like bowel obstruction or ischemia. Prompt medical evaluation is essential to determine the appropriate intervention and ensure the client's safety.

Choice A rationale

Alzheimer's disease affects cognitive function, making it difficult for clients to process and remember complex instructions. Limiting instructions to two steps at a time reduces cognitive overload and enhances the client's ability to follow directions. This approach is supported by evidence-based guidelines for managing Alzheimer's, which emphasize simplifying tasks to match the individual's functional capabilities.

Choice B rationale

Encouraging independence in activities of daily living (ADLs) may lead to frustration and increased agitation in clients with Alzheimer's. As cognitive decline progresses, the client often lacks the ability to independently complete ADLs, requiring structured assistance to prevent anxiety and promote safety.

Choice C rationale

Using socialization as a distractor during agitation is not effective because it may overstimulate the client, worsening the agitation. Alzheimer's clients are often sensitive to changes in environment and increased activity, necessitating calm and consistent approaches during episodes of distress.

Choice D rationale

Varying staff providing care disrupts consistency and routine, which are crucial for clients with Alzheimer's. Familiar caregivers help foster trust and reduce confusion, aligning with care practices that prioritize stability and minimize anxiety caused by frequent changes in personnel.