A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

I should change my stoma pouch 30 minutes after meals.

I should cut my pouch opening 1/8 inch larger than my stoma.

I should clean my stoma with moisturizing soap.

I should expect my stoma to be blistered.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the stoma pouch 30 minutes after meals is not recommended, as meal timing does not dictate pouch changes. Pouches are typically changed every 3-7 days or if leaking, to prevent skin irritation. This statement reflects a misunderstanding, as it suggests an incorrect schedule unrelated to stoma care needs.
Choice B reason: Cutting the pouch opening 1/8 inch larger than the stoma ensures a snug fit, preventing leakage while protecting peristomal skin from irritation by digestive enzymes. Proper sizing maintains skin integrity and pouch adherence, supporting effective ostomy management. This statement demonstrates correct understanding of stoma care techniques.
Choice C reason: Cleaning the stoma with moisturizing soap is incorrect, as soaps with oils or fragrances can irritate peristomal skin and impair pouch adhesion. Mild, non-residue soap and water are recommended to maintain skin integrity. This statement indicates a misunderstanding of proper stoma cleaning practices.
Choice D reason: Expecting the stoma to be blistered is incorrect, as a healthy stoma should be pink, moist, and free of irritation. Blistering indicates complications like infection or poor pouch fit. This statement reflects a misunderstanding of normal stoma appearance and care, suggesting potential issues requiring intervention.

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Correct Answer is A

Explanation

Choice A reason: A subdural hematoma increases complication risk during electroconvulsive therapy (ECT) due to elevated intracranial pressure. ECT-induced seizures can worsen bleeding or cause herniation, posing significant neurological risks. This condition requires careful evaluation, making it the critical risk factor for complications.
Choice B reason: Hyperthyroidism may increase heart rate or metabolic demand but is not a primary risk for ECT complications. With proper management, it poses minimal risk compared to intracranial issues, so this is not the most concerning condition, making it incorrect.
Choice C reason: Renal calculi do not directly impact ECT safety, as they are unrelated to neurological or cardiovascular risks during seizures. This condition is manageable and not a significant complication risk, so it is incorrect for this scenario.
Choice D reason: Diabetes mellitus requires monitoring during ECT due to fasting or medication effects, but it is not a primary risk for complications. With proper glucose management, risks are minimal, so this is incorrect compared to a subdural hematoma’s impact.

A. Experiencing delusions B. A history of being in prison C. A history of violent behavior D. Substance use disorder

Correct Answer is C

Explanation

Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.

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A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is scheduled for electroconvulsive therapy. Which of the following conditions should the nurse identify as an increased risk for complications?

Correct Answer is A

Explanation

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

Correct Answer is C

Explanation

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