A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?
"Your colostomy will not produce formed stool."
"You should expect your stoma to be a purple color."
"The end of the stoma will be painful after this procedure."
"You will have a stoma in your left lower abdomen."
The Correct Answer is D
A. "Your colostomy will not produce formed stool." A sigmoid colostomy is located in the lower part of the large intestine where stool is typically more formed. Therefore, this statement is incorrect and should not be included in the teaching.
B. "You should expect your stoma to be a purple color." A healthy stoma should be pink or red and moist. A purple, dusky, or dark color may indicate compromised blood flow to the stoma and is a sign of a medical emergency. This statement is incorrect.
C. "The end of the stoma will be painful after this procedure." The stoma itself does not have nerve endings, so it should not be painful. Pain around the incision site may occur, but the stoma itself should not be painful. This statement is incorrect.
D. "You will have a stoma in your left lower abdomen." The sigmoid colon is located on the lower left side of the abdomen, so the stoma for a sigmoid colostomy is typically placed in this area. This statement is correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Face the client when speaking to them. This is the correct action. Facing the client while speaking helps them use any remaining vision they have to interpret facial expressions and lip movements, which can enhance communication.
B. Open shades on windows in the client's room to provide direct lighting. Direct lighting can cause glare, which may worsen vision impairment. It is better to use indirect lighting to avoid glare.
C. Use gestures to communicate with the client. While gestures can be useful for some individuals, they are not as effective for clients with vision impairment who may not be able to see them clearly.
D. Speak loudly when talking to the client. There is no need to speak loudly unless the client also has a hearing impairment. Speaking loudly could be perceived as shouting, which may be uncomfortable for the client.
Correct Answer is D
Explanation
A. Blood glucose levels return to the expected reference range. Blood glucose levels are more likely to be elevated due to prolonged stress during the exhaustion stage, not normalized.
B. Blood pressure increases. During the exhaustion stage, the body's resources are depleted, and blood pressure may drop rather than increase.
C. Depression: The exhaustion stage is characterized by physical and psychological symptoms such as depression, fatigue, and reduced immune function.
D. Dilation of pupils: Pupil dilation occurs during the alarm stage of the general adaptation syndrome, not during the exhaustion stage.
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