A nurse is assessing a client who has a colostomy. Which of the following findings show the nurse report to the provider?
The skin around the stoma is red.
The ostomy is draining frequently.
The stool is yellow-green.
The stoma is pale in color.
The Correct Answer is D
A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.
B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.
C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.
D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Face the client when speaking to them. This is the correct action. Facing the client while speaking helps them use any remaining vision they have to interpret facial expressions and lip movements, which can enhance communication.
B. Open shades on windows in the client's room to provide direct lighting. Direct lighting can cause glare, which may worsen vision impairment. It is better to use indirect lighting to avoid glare.
C. Use gestures to communicate with the client. While gestures can be useful for some individuals, they are not as effective for clients with vision impairment who may not be able to see them clearly.
D. Speak loudly when talking to the client. There is no need to speak loudly unless the client also has a hearing impairment. Speaking loudly could be perceived as shouting, which may be uncomfortable for the client.
Correct Answer is A
Explanation
A. Reflex incontinence: Reflex incontinence occurs when the bladder muscle contracts and urine leaks out (often in large amounts) without any warning or urge. This is common in clients with nerve damage or spinal cord injuries, making it the correct answer.
B. Urge incontinence: Urge incontinence is characterized by a sudden, intense urge to urinate followed by involuntary urine loss. It is often associated with an overactive bladder, not nerve damage.
C. Stress incontinence: Stress incontinence involves urine leakage during physical activity or exertion (e.g., coughing, sneezing) that increases abdominal pressure. It is not typically related to nerve damage.
D. Overflow incontinence: Overflow incontinence occurs when the bladder is unable to empty properly, leading to dribbling of urine. It is often seen in conditions where the bladder muscles are weak or there is an obstruction. While it can be related to nerve damage, reflex incontinence is more accurate for this scenario.
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