Nokea
A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance?
- A. I wish my sexual relationship with my partner was like it was before.
- B. I have my partner empty the bag for me, so I don't have to look at it
- C. I look forward to having normal bowel movements again.
- D. I will attend a support group to help me handle difficulties when they occur.
Correct Answer: D
Rationale: Attending a support group shows proactive acceptance and coping with the ileostomy. Other statements reflect denial or avoidance of the new reality.
You may also like to solve these questions
A nurse is caring for a client who has dysphagia following a stroke. The nurse should recommend a referral to which of the following members of the interdisciplinary team?
- A. Speech therapist
- B. Respiratory therapist
- C. Occupational therapist
- D. Physical therapist
Correct Answer: A
Rationale: A speech therapist addresses dysphagia by assessing swallowing and recommending strategies, critical after a stroke. Other therapists focus on different rehabilitation aspects.
Nurses' Notes Day 1: Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up? (Ski accident client)
- A. Findings of right lower extremity assessment
- B. Oxygen saturation
- C. Right pedal pulses
- D. Level of consciousness
- E. Temperature
- F. Pain level
- G. X-ray results
Correct Answer: A,C,F,G
Rationale: Right leg swelling, weak pulses, pain, and X-ray (fracture) indicate urgent issues like compartment syndrome.
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Inform the client of the adverse effect of diarrhea.
- B. Monitor the client for weight loss.
- C. Advise the client about increased dry mouth.
- D. Check the client for increased hypopigmentation under the patch.
Correct Answer: C
Rationale: Clonidine, an antihypertensive, commonly causes dry mouth as a side effect, and advising the client about this is appropriate for the care plan. Diarrhea, weight loss, and hypopigmentation are not typical effects associated with transdermal clonidine.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client has a history of breast cancer.
- D. The client consumed citrus juice 3 days before the test
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can cause GI irritation and bleeding, leading to a false-positive fecal occult blood test. The other factors are unlikely to affect the result directly.