A nurse is caring for a client.

Exhibits

A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment.

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.

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.