Nokea
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
- A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
- B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
- C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
- D. I can see that you are upset. Would you like to share your concerns with me?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
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The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy
- B. Contraction
- C. Gangrene
- D. Rubor
Correct Answer: C
Rationale: A black great toe in a client with PVD likely indicates gangrene, resulting from tissue necrosis due to severe ischemia from arterial occlusion. Atrophy causes muscle wasting, contraction is not a relevant term, and rubor refers to reddish discoloration, not black.
The nurse is caring for a client with cancer experiencing chronic pain and episodes of breakthrough pain. Which prescription should the nurse request from the primary healthcare provider (PHCP) to provide effective pain control?
- A. Hydromorphone via patient-controlled analgesia (PCA)
- B. Morphine intramuscular (IM) as needed (PRN) for pain
- C. Oxycodone extended-release (ER) by mouth (PO)
- D. Ketorolac via intravenous (IV) push
Correct Answer: A
Rationale: Hydromorphone via PCA allows for both continuous and patient-controlled dosing, ideal for managing chronic cancer pain with breakthrough episodes.
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
- A. To support the lower portion of the leg.
- B. To support the thigh and upper leg.
- C. To allow attachment of the skeletal pin.
- D. To prevent flexion deformities in the ankle and foot.
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.
The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position?
- A. Trendelenburg
- B. Supine
- C. Right lateral decubitus with head end elevated
- D. Prone
Correct Answer: B
Rationale: Supine position is appropriate for angle-closure glaucoma to avoid increasing intraocular pressure. Trendelenburg and prone positions may worsen pressure, and right lateral decubitus is not specific to this condition.
In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? The client will:
- A. Have normalized albumin levels.
- B. Return to ideal body weight.
- C. Gain 1 lb every 2 weeks.
- D. Maintain current weight.
Correct Answer: D
Rationale: Maintaining current weight is a realistic goal for a client with advanced liver cancer and poor nutrition, as weight gain or normalized albumin may be unachievable due to disease progression.