An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

Use background music to promote relaxation.

Turn on overhead lights while reviewing instructions.

Stand behind the client to avoid intimidation.

Provide handouts written at a 12th grade reading level.

Answer and Explanation

The Correct Answer is D

A.   While music can be relaxing, it may also be distracting and make it difficult for the client to focus on the instructions.
B.   Bright overhead lights can be uncomfortable and may even cause strain on the eyes. It's generally better to use soft, natural lighting when reviewing instructions.
C.   Standing behind the client can make them feel intimidated or uncomfortable, especially if they are already feeling anxious or overwhelmed. It's better to stand in front of the client and maintain eye contact to show that you are engaged and attentive.
D.   Older adults may have difficulty understanding written information that is too complex. Providing handouts written at a 12th grade reading level ensures that the client can easily comprehend the instructions and follow them at home.

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Correct Answer is A

Explanation

A. Allowing privacy for the family and client is a compassionate and appropriate action, especially as the client's death is imminent. This respects the client's wishes and provides a supportive environment for the family to process their emotions and say their goodbyes.
B. Continuously measuring blood pressure in this scenario is less appropriate because the client is in the final stages of life and their focus should be on comfort rather than monitoring vital signs. Frequent blood pressure measurements may be distressing for the family and do not align with the goals of end- of-life care, which prioritize comfort and dignity.
C. Teaching the family to use an oral suction device is not appropriate at this stage because the client is actively dying, and such interventions are not typically useful or necessary in end-of-life care. The focus should be on providing comfort rather than invasive procedures or teaching new skills to family members.
D. Applying oxygen and elevating the head of the bed can be appropriate interventions for clients experiencing respiratory distress; however, this may conflict with the advance directive if the directive explicitly states no resuscitative measures

A. Visible subcutaneous tissue with sloughing. B. An area of erythema that is painful to touch. C. Shallow open ulcer with a red pink wound bed. D. A deep pocket of infection and necrotic tissues.

Correct Answer is C

Explanation

A. This description is more characteristic of a Stage 3 or Stage 4 pressure injury. Stage 3 pressure injuries involve full-thickness skin loss and may expose subcutaneous tissue, and Stage 4 involves extensive damage with possible exposure of muscle, bone, or tendon. Sloughing (a type of necrotic tissue) is not typical of Stage 2 pressure injuries.
B. This description is more indicative of a Stage 1 pressure injury. Stage 1 injuries are characterized by non-blanchable erythema of intact skin, and pain or discomfort in the affected area is common. Stage 1 does not involve the loss of skin integrity, so it would not be the appearance of a Stage 2 injury.
C. This description accurately matches the appearance of a Stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red or pink wound bed. It does not extend through the entire thickness of the skin.
D. This description aligns with Stage 3 or Stage 4 pressure injuries, which involve full-thickness skin loss with possible necrotic tissue and deep pockets of infection. These stages involve significant tissue damage beyond what is seen in Stage 2 injuries.

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An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is C

Explanation

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

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