The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse?

Choice A Reason:

A rosebud-like stoma orifice is a normal finding for a newly created colostomy. This appearance indicates that the stoma is healthy and well-formed. The stoma should protrude slightly from the abdomen and have a pink or red color, similar to the inside of the mouth. This indicates good blood flow and proper healing. Therefore, a rosebud-like stoma orifice does not need to be reported to the provider.

Choice B Reason:

A stoma oozing red drainage can be concerning, but it is not uncommon for a new stoma to have some minor bleeding or oozing, especially in the immediate postoperative period. This can occur due to the delicate nature of the tissue and the recent surgical intervention. However, if the drainage is excessive or persistent, it should be monitored closely and reported if it does not improve. Minor oozing is generally expected and does not necessarily indicate a serious problem.

Choice C Reason:

A shiny, moist stoma is a normal finding and indicates that the stoma is healthy. The stoma should be moist and have a shiny appearance, similar to the inside of the mouth. This moisture is necessary for the proper function and health of the stoma. Therefore, a shiny, moist stoma does not need to be reported to the provider.

Choice D Reason:

A purplish-colored stoma is an abnormal finding and should be reported to the provider immediately. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. A healthy stoma should be pink or red, indicating good blood circulation. Any deviation from this color, especially a purplish or dark color, is a sign of potential ischemia or other serious complications that require immediate medical attention.

Choice A Reason:

Continuing to monitor is the most appropriate action in this scenario. The patient has a regular heart rhythm and a heart rate of 60 beats per minute, which is within the normal range for sinus bradycardia. The PR interval is 0.20 seconds, which is at the upper limit of normal. The patient’s vital signs are stable, with a blood pressure of 118/68 mm Hg, a respiratory rate of 16 breaths per minute, and a temperature of 98.8°F (37°C). There are no signs of hemodynamic instability or symptoms that would necessitate immediate intervention. Therefore, ongoing monitoring is sufficient to ensure the patient’s condition remains stable.

Choice B Reason:

Administering clonidine is not appropriate in this situation. Clonidine is an antihypertensive medication that can lower blood pressure and heart rate. Given that the patient’s blood pressure and heart rate are within normal ranges, administering clonidine could potentially cause hypotension and bradycardia, leading to adverse effects. Therefore, clonidine is not indicated for this patient.

Choice C Reason:

Administering atropine is not necessary for this patient. Atropine is used to treat symptomatic bradycardia, where the heart rate is abnormally slow and causing symptoms such as dizziness, hypotension, or syncope. In this case, the patient’s heart rate is 60 beats per minute, which is within the normal range for sinus bradycardia, and there are no symptoms indicating the need for atropine. Therefore, atropine is not required.

Choice D Reason:

Administering digoxin is also not appropriate. Digoxin is a cardiac glycoside used to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It can slow the heart rate and increase the force of cardiac contractions. In this scenario, the patient does not have any indications for digoxin therapy, such as heart failure or atrial fibrillation, and their heart rate is already within the normal range. Therefore, digoxin is not indicated.