A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Rationale:

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.

B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.

C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.

D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.

Rationale:

• Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
• Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
• Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
• Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
• Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.