A nurse in a provider's office is collecting data from a client who is 1 month postoperative following an ileostomy. Which of the following statements by the client indicates the client is in the acceptance stage of grieving?
"I have purchased a stoma cap I can use when needed."
"I have my partner empty my pouch for me every morning."
"I am embarrassed by the odor that comes from my ileostomy."
"I miss going to my church meetings because of this ostomy."
The Correct Answer is A
Choice A reason: Purchasing a stoma cap that can cover and conceal the ileostomy when not in use indicates that the client is in the acceptance stage of grieving, as it shows that they have adapted to their new condition and are able to resume their normal activities and social interactions.
Choice B reason: Having their partner empty their pouch for them every morning indicates that the client is in the denial stage of grieving, as it shows that they are avoiding or rejecting their new condition and are dependent on others for their care.
Choice C reason: Being embarrassed by the odor that comes from their ileostomy indicates that the client is in the depression stage of grieving, as it shows that they have low self-esteem and negative feelings about their new condition and its impact on their quality of life.
Choice D reason: Missing going to their church meetings because of their ostomy indicates that the client is in the anger stage of grieving, as it shows that they have resentment and frustration about their new condition and its interference with their previous routines and values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Ammonia 55 mg/dL is within the normal range of 15 to 60 mg/dL and does not indicate any liver dysfunction or bleeding risk.
Choice B reason: Bilirubin 1.0 mg/dL is within the normal range of 0.3 to 1.2 mg/dL and does not indicate any liver damage or jaundice.
Choice C reason: Aspartate aminotransferase 34 units/L is within the normal range of 10 to 40 units/L and does not indicate any liver inflammation or injury.
Choice D reason: Platelets 60,000/mm³ is below the normal range of 150,000 to 450,000/mm³ and indicates thrombocytopenia, which is a low platelet count that can increase the risk of bleeding during or after the liver biopsy. The nurse should report this value to the provider and monitor the client for signs of bleeding, such as bruising, petechiae, hematuria, or melena.
Correct Answer is B
Explanation
Choice A reason: Pupillary dilation is not a sign of opioid toxicity, but rather of opioid withdrawal or stimulant overdose. Opioid toxicity causes pupillary constriction or miosis.
Choice B reason: Hypotension is a sign of opioid toxicity sign of opioid toxicity, as opioids can depress the central nervous system and reduce cardiac output and peripheral resistance.
Choice C reason: Chest pain is not a sign of opioid toxicity, but rather of cardiac ischemia or infarction, which can be caused by cocaine or other stimulants.
Choice D reason: Diaphoresis is not a sign of opioid toxicity, but rather of opioid withdrawal or hyperthermia, which can be caused by ecstasy or other stimulants.
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