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 B

Explanation

B. This client's excitement to learn about a new prosthesis indicates a positive attitude towards rehabilitation and a willingness to engage in the learning process. Their enthusiasm suggests a high level of motivation to adapt to their new prosthesis and incorporate it into their daily life. Therefore, this client exhibits a high motivation to learn.
A. This client's struggle with following nursing directives regarding discharge goals suggests a lack of motivation or difficulty engaging in the rehabilitation process. They may be experiencing challenges or barriers that are impeding their progress. Therefore, they do not exhibit the highest motivation to learn at this time.
C. While this client may have valuable experience and insights to share with newcomers, being a "coach" does not necessarily indicate a high motivation to learn for themselves. While they may be motivated to help others, it doesn't necessarily reflect their own eagerness to engage in learning activities for their own rehabilitation goals.

D. This client's eagerness to be discharged may suggest a desire to move on from the rehabilitation facility rather than a motivation to engage in learning activities related to their rehabilitation. They may be more focused on the end goal of leaving the facility rather than actively participating in the rehabilitation process.

A. "My family will need to shoulder the burden of my care." B. "I will be supported so I can be as independent as possible." C. "I should turn my care decisions over to my partner. D. "My neurologist will no longer care for me."

Correct Answer is B

Explanation

B. This statement demonstrates an understanding of palliative care as a supportive approach focused on optimizing independence and quality of life. Palliative care emphasizes symptom management, psychosocial support, and enhancing functional abilities to enable patients to live as fully and independently as possible, even in the context of a progressive neurologic disease. This statement aligns with the principles of palliative care, which aim to empower patients to make choices and maintain control over their lives.
A. This statement reflects a perception of palliative care as solely placing the responsibility of care on the family. While family support is an essential component of palliative care, it is not the sole responsibility of the family. Palliative care aims to provide comprehensive support to patients with serious illnesses, addressing physical, emotional, social, and spiritual needs. It involves a collaborative approach involving healthcare professionals, patients, and their families to ensure holistic care and quality of life.

C. This statement suggests a misconception about palliative care, equating it with relinquishing control of care decisions to a partner or caregiver. In reality, palliative care emphasizes patient-centered decision-making and supports patients in expressing their preferences, values, and goals of care. While caregivers play an important role in the palliative care team, ultimate decision-making authority rests with the patient, and care plans are tailored to align with the patient's wishes and priorities.
D. This statement reflects a misunderstanding of palliative care as a replacement for disease-specific medical care, such as neurology. Palliative care is not mutually exclusive with disease-focused treatment but rather complements it by addressing the broader physical, emotional, and social needs of patients with serious illnesses, including progressive neurologic diseases. Palliative care can be provided concurrently with disease-specific treatments and involves a multidisciplinary team, which may include specialists like neurologists, to ensure comprehensive care.

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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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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)