The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)

stoma is shiny and moist

stoma is deep pink

peristomal skin is not reddened or tender

abdomen flat

bowel sounds present 8 to 10 clicks/gurgles per minute

Answer and Explanation

Correct Answer : A,B,C,D,E

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B.   A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C.   The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D.   A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E.   Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. The health status prior to the accident can influence how individuals respond to stress. Clients with pre-existing medical conditions, chronic pain, or disabilities may experience increased stress due to concerns about exacerbation of their conditions, recovery, or long-term consequences. Therefore, health status prior to the accident can impact the degree of stress experienced.
B. Age can influence individuals' coping mechanisms and resilience in response to stress. Younger individuals may have less life experience and coping skills, while older individuals may have accumulated more experience and developed better coping strategies over time. Additionally, age-related factors such as physical resilience and social support networks can affect how individuals respond to stressors. Therefore, different ages can influence the degree of stress experienced.
C. External resources such as social support networks, access to healthcare, financial stability, and community resources can significantly impact individuals' ability to cope with stress. Clients with strong support systems, adequate access to medical care, and financial security may experience lower levels of stress compared to those lacking these resources. Therefore, external resources can influence the degree of stress experienced.
D. Individual problem-solving skills play a crucial role in how individuals perceive and manage stressful situations. Clients with strong problem-solving skills may feel more confident in their ability to address challenges and may experience lower levels of stress. Conversely, clients with limited problem-solving skills may feel overwhelmed and experience higher levels of stress. Therefore, individual problem- solving skills can influence the degree of stress experienced.
E. Personality traits such as resilience, optimism, neuroticism, and coping styles can impact how individuals respond to stressors. For example, individuals with resilient personalities and positive coping styles may adapt more effectively to stressors and experience lower levels of stress. Conversely, individuals with neurotic personalities or maladaptive coping styles may be more prone to experiencing heightened stress levels. Therefore, personalities can influence the degree of stress experienced.

A. Research shows that people in general get more than enough sleep. B. Teenagers have a natural tendency to wake up earlier. C. Sleep needs remain constant over the course of a person's lifetime. D. Older adults experience a progressive decrease in deep sleep.

Correct Answer is D

Explanation

D. As individuals age, there is a natural decline in the amount of deep sleep (slow-wave sleep or Stage N3 sleep) they experience. Older adults tend to spend less time in deep sleep and may experience more fragmented sleep patterns, with more frequent awakenings during the night. This reduction in deep sleep is a normal part of the aging process and is associated with changes in sleep architecture and physiology.
A. Research indicates that a significant portion of the population does not get enough sleep, with many adults experiencing sleep deprivation due to various factors such as lifestyle, work schedules, and sleep disorders.
B. Teenagers often have a natural tendency to stay up later and have difficulty waking up early due to changes in their circadian rhythm during adolescence. This shift in sleep patterns, known as delayed sleep phase syndrome, can result in later bedtimes and waking times for teenagers.

C. Sleep needs typically change over the course of a person's lifetime. Infants and young children require more sleep than adults, with sleep duration gradually decreasing as individuals age.
Additionally, factors such as lifestyle, health status, and environmental influences can affect sleep needs at different stages of life.

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

Two clients have been in a similar motor vehicle accident, and have similar injuries. The nurse observes each client's different responses to this stressor. The nurse understands that the degree of stress each client experiences from the crash may be influenced by their: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse recognizes that which statement regarding sleep is true?

Correct Answer is D

Explanation

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The nurse promotes good quality sleep for their clients based on the knowledge that sleep: (SELECT ALL THAT APPLY)

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)