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 D
Explanation
A. Metabolic Acidosis: Clients with COPD are more prone to respiratory acid-base imbalances rather than metabolic ones.
B. Respiratory Alkalosis: COPD is characterized by chronic retention of CO₂, leading to acidosis, not alkalosis.
C. Metabolic Alkalosis: Metabolic alkalosis is not commonly associated with COPD.
D. Respiratory Acidosis: Clients with COPD are at risk for respiratory acidosis due to the retention of carbon dioxide (CO₂), which occurs when alveolar ventilation is impaired.
Correct Answer is C
Explanation
A. Body Image: Body image stressors relate to how a person perceives their physical self. This is not relevant to the scenario of work and family stress.
B. Self-esteem: Self-esteem stressors relate to a person’s sense of self-worth. While stress from work and family can affect self-esteem, the primary issue here is more related to role performance.
C. Role performance: Role performance stressors relate to how well an individual perceives they are fulfilling their roles in life, such as work, parenting, or caregiving. The client’s stress about balancing work and family responsibilities indicates a role performance issue. This is the correct answer.
D. Identity: Identity stressors involve a person’s sense of who they are. While stress from work and family can affect identity, the primary issue here is more specifically related to role performance.
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