A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

Attending a support group to seek help and guidance for handling difficulties indicates the client's acceptance of having a new ileostomy. It demonstrates a proactive approach to coping with the challenges associated with living with an ileostomy.

Choice B rationale:

Having a partner empty the bag for the client to avoid looking at it may indicate avoidance or denial rather than acceptance. While support from a partner is essential, it's also important for the client to actively participate in self-care and adaptation.

Choice C rationale:

Looking forward to having normal bowel movements again may indicate a lack of acceptance or unrealistic expectations since having an ileostomy means a change in bowel function. The client should be educated about the permanence of the ileostomy.

Choice D rationale:

Wishing for a return to the pre-ileostomy sexual relationship may indicate difficulty accepting the changes in body image and function that come with an ileostomy. It may also suggest unrealistic expectations. The client should be encouraged to seek support and counseling for body image issues and sexual concerns.

Choice A rationale:

Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.

Choice B rationale:

Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.

Choice C rationale:

Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.

Choice D rationale:

Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.