A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
Emphasize the fact that the colostomy is temporary measure and is not permanent.
Encourage the client to conduct online research into colostomies.
Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.
Engage the client in dialogue about the implications of having the colostomy.
The Correct Answer is D
Choice A reason: Stating that a colostomy is temporary might provide false hope if the status is uncertain, and it does not help the patient cope with their current reality. To improve body image, the patient must process their feelings about their current physical state rather than simply waiting for it to change.
Choice B reason: While education is helpful, unguided online research can expose the patient to graphic images or misinformation that may actually worsen anxiety and negative body image. The nurse should provide curated resources rather than encouraging broad, unsupervised internet searches during the initial period of psychological adjustment.
Choice C reason: Logic and "rationalizing" why the surgery was necessary (e.g., to treat cancer) often fails to address the emotional trauma of body disfigurement. A patient can be grateful to be alive while still feeling devastated by the presence of a stoma; the nurse must address the latter directly.
Choice D reason: Open dialogue allows the patient to express fears, grief, and concerns about intimacy, clothing, and social life. This therapeutic communication helps the nurse identify specific misconceptions and facilitates the patient's transition toward acceptance by validating their feelings and encouraging a realistic integration of the stoma into their self-concept.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: In peritoneal dialysis, the effluent (the drained fluid) should normally be clear or straw-colored. Opaque or cloudy effluent is the earliest and most significant sign of peritonitis, a serious infection of the peritoneum. The priority action is to obtain a sample for culture and sensitivity to identify the pathogen.
Choice B reason: Flushing the tubing with normal saline might be appropriate if there was a suspected mechanical blockage or slow drainage, but it does not address the primary concern of infection indicated by the opaque color. Clinical assessment for infection must take precedence over mechanical maintenance of the catheter when effluent appearance changes.
Choice C reason: Checking the catheter for kinking or curling is a standard troubleshooting step for poor inflow or outflow of dialysate. However, these mechanical issues do not cause the effluent to become opaque or cloudy. Cloudy fluid specifically indicates the presence of white blood cells or bacteria, necessitating an infectious workup.
Choice D reason: Warming dialysate should only be done using a specialized warming cabinet or heating pad, never a microwave, due to the risk of uneven heating and internal burns. Furthermore, this is a preventative measure for patient comfort during instillation and does not respond to the urgent assessment finding of potentially infected effluent.
Correct Answer is D
Explanation
Choice A reason: Glomerulonephritis is an intrarenal (intrinsic) cause of acute kidney injury. It involves inflammation and damage to the glomerular capillaries themselves, often following a streptococcal infection or due to autoimmune diseases. Because the damage is located within the functional tissue of the kidney, it is not classified as prerenal.
Choice B reason: Pregnancy itself is not a direct cause of AKI, though complications like preeclampsia can lead to renal issues. Preeclampsia usually involves intrarenal damage due to vasospasm and endothelial injury. Pregnancy-related obstructions would be considered postrenal. It does not represent a classic prerenal mechanism of systemic hypoperfusion.
Choice C reason: Ureterolithiasis (kidney stones in the ureter) is a postrenal cause of acute kidney injury. It creates a mechanical obstruction that prevents the flow of urine out of the kidney. This leads to hydronephrosis and increased pressure that stops filtration, but the initial problem occurs after the kidney, not before it.
Choice D reason: Burns are a classic cause of prerenal AKI. Major burns lead to massive fluid loss, systemic inflammatory response, and third-spacing of fluids, resulting in severe hypovolemia. This decrease in circulating blood volume leads to renal hypoperfusion and a drop in the glomerular filtration rate before any structural damage occurs to the kidneys.
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