A nurse is reinforcing teaching with a client who is to begin taking lansoprazole.
Which of the following statements by the client indicates an understanding of the teaching?

Choice A rationale

Cutting the skin barrier opening 1/4 inch larger than the stoma prevents pressure on the stoma while ensuring a secure fit. This size accommodates natural stoma expansion during peristalsis, minimizes leakage, and reduces irritation to the peristomal skin.

Choice B rationale

Emptying the pouch when it is 1/3 to 1/2 full is recommended to prevent excessive weight, which can cause the adhesive barrier to loosen. Regular emptying maintains hygiene, reduces odors, and ensures comfort for the client, enhancing ostomy care.

Choice C rationale

Cleansing the skin surrounding the stoma with moisturizing soap is inappropriate as it leaves a residue that can interfere with the adhesive barrier's seal. Instead, non-moisturizing, residue-free cleansers are recommended to optimize ostomy barrier adhesion.

Choice D rationale

Using a standard enema set to irrigate the colostomy is not standard practice. Colostomy irrigation requires specialized equipment and careful technique to prevent mucosal trauma. Routine irrigation is typically advised for clients with specific medical conditions or stoma types.

C. Unable to remember their adult children's names.

D. Unable to answer a judgment task correctly.

Answer and explanation

The correct answer is Choice A.

Choice A rationale

Inability to remain fully awake after head trauma indicates decreased neurological function, a sign of intracranial injury or bleeding, requiring immediate attention. Reduced consciousness compromises airway protection and perfusion. Normal intracranial pressure ranges from 7 to 15 mmHg in adults; elevated levels can indicate pathology. This finding is critical for prioritization to prevent irreversible brain damage.

Choice B rationale

Difficulty repeating named objects suggests short-term memory loss, often linked to conditions like concussion. However, it does not pose an immediate life threat like compromised consciousness does. Neurological evaluation is necessary but secondary in priority unless paired with other severe symptoms like loss of consciousness or seizures.

Choice C rationale

Failure to recall adult children’s names suggests long-term memory impairment. While it may indicate brain injury or dementia exacerbation, it is not an immediate threat compared to decreased alertness. Cognitive decline should be addressed later after stabilizing potential life-threatening conditions.

Choice D rationale

Errors in judgment tasks reflect possible frontal lobe dysfunction or cognitive impairment. Though concerning, this is not the most urgent finding unless associated with symptoms like increased intracranial pressure or stroke. Addressing primary life-sustaining functions remains the priority.