A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?

"I will attend a support group to help me handle difficulties when they occur.”

"I have my partner empty the bag for me, so I don't have to look at it.”

"I look forward to having normal bowel movements again.”

"I wish my sexual relationship with my partner was like it was before.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attending a support group to seek help and guidance for handling difficulties indicates the client's acceptance of having a new ileostomy. It demonstrates a proactive approach to coping with the challenges associated with living with an ileostomy.

Choice B rationale:

Having a partner empty the bag for the client to avoid looking at it may indicate avoidance or denial rather than acceptance. While support from a partner is essential, it's also important for the client to actively participate in self-care and adaptation.

Choice C rationale:

Looking forward to having normal bowel movements again may indicate a lack of acceptance or unrealistic expectations since having an ileostomy means a change in bowel function. The client should be educated about the permanence of the ileostomy.

Choice D rationale:

Wishing for a return to the pre-ileostomy sexual relationship may indicate difficulty accepting the changes in body image and function that come with an ileostomy. It may also suggest unrealistic expectations. The client should be encouraged to seek support and counseling for body image issues and sexual concerns.

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Correct Answer is D

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

Choice D rationale:

Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

A. Place a padded tongue blade in the child's mouth. B. Place a pillow under the child's head. C. Turn the child onto their back. D. Restrain the child's upper extremities.

Correct Answer is B

Explanation

Choice A rationale:

Placing a padded tongue blade in the child's mouth is not recommended during a tonic-clonic seizure. This action can cause injury to the child's mouth or teeth and does not help manage the seizure itself.

Choice C rationale:

Turning the child onto their back is generally the correct action to take during a seizure to ensure an open airway. However, this should be done gently and after ensuring the child's safety. Placing a pillow under the head is also important to prevent head injury during the seizure.

Choice D rationale:

Restraining the child's upper extremities is not recommended during a tonic-clonic seizure. It can lead to injury for both the child and the healthcare provider and is not an effective way to manage the seizure. The priority is to ensure the child's safety and protect them from harm.

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A nurse is evaluating a client's acceptance of having a new ileostomy.Which of the following statements by the client indicates acceptance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

Explanation

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A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?