A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?
The client reports a pain level of 6 on a scale from O to 10.
The client refuses to look at the colostomy.
The colostomy has had no output.
The Stoma appears dark purple in color.
The Correct Answer is D
A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected after surgery and should be managed, but it is not immediately life-threatening or the highest priority.
B. The client refuses to look at the colostomy: Emotional adjustment is important, but this does not pose an immediate physical risk to the client and can be addressed over time with support and education.
C. The colostomy has had no output: It is common for a new colostomy to have delayed output within the first 24 hours postoperatively, so this finding is expected and not immediately concerning.
D. The stoma appears dark purple in color: A dark purple stoma indicates compromised blood flow or ischemia, which is a medical emergency requiring immediate intervention to prevent tissue necrosis and further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
- Minimize environmental stimuli for the client: This is appropriate because clients experiencing acute mania are highly distractible and overstimulated. A low-stimulation environment helps reduce agitation and promotes safety.
- Weigh the client each day: Daily weights are necessary as manic clients often exhibit decreased nutritional intake and increased physical activity, placing them at risk for weight loss and dehydration.
- Provide the client with high-calorie fluids every hour: Frequent intake of calorie-dense fluids supports the client’s nutritional needs without requiring prolonged focus or interruption of hyperactive behavior.
- Encourage the client to avoid napping during the day: This is contraindicated because rest is crucial during manic episodes. Encouraging naps supports mood stabilization and prevents exacerbation of manic symptoms due to sleep deprivation.
Correct Answer is D
Explanation
A. Sacrum: The sacrum is typically assessed for pressure injuries but is not the most reliable site for detecting cyanosis in clients with dark skin because of variable pigmentation.
B. Shoulders: The shoulders have significant pigmentation and are not ideal for assessing cyanosis in dark-skinned clients due to difficulty distinguishing color changes.
C. Area of trauma: Trauma sites may show redness or bruising unrelated to cyanosis, making them unreliable for assessing oxygenation status.
D. Palms of the hands: The palms have less melanin and are lighter in color, making them a better site to observe for cyanosis in clients with dark skin due to clearer visualization of bluish discoloration.
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