A nurse is caring for a client in an outpatient clinic.

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

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as evidenced by the client's

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.

An ascending colostomy is a surgical opening created in the ascending colon to divert fecal flow to an external pouch. Because it is located in the proximal large intestine, stool output is typically liquid to semi-liquid with high enzyme content. Postoperative teaching focuses on stoma care, expected stool characteristics, and recognition of complications such as ischemia. Monitoring stoma color is critical because it reflects blood supply and tissue viability.

Rationale:
A. Avoiding nuts is not a universal requirement for clients with a colostomy. While some foods may initially cause gas or blockage concerns, dietary restrictions are individualized rather than completely eliminating specific food groups. Clients are usually encouraged to gradually reintroduce foods while monitoring tolerance.

B. Irrigating the colostomy every day is not appropriate for an ascending colostomy. Irrigation is typically used for descending or sigmoid colostomies to regulate bowel emptying. An ascending colostomy produces frequent liquid output, making irrigation unnecessary and ineffective.

C. Expecting formed stool is incorrect for an ascending colostomy because stool at this level of the colon is still liquid to semi-liquid due to limited water reabsorption. Formed stool is more typical of descending or sigmoid colostomies where more water has been absorbed.

D. A stoma that appears purple is an abnormal finding indicating compromised blood flow or possible ischemia. A healthy stoma should be pink to red and moist. Any color change such as purple, dusky, or black should be reported immediately because it may indicate necrosis requiring urgent intervention.

This question focuses on identifying major depressive disorder in a client presenting with alcohol use, flat affect, poor hygiene, social withdrawal, job loss, and verbalization of hopelessness (“life is not worth living”). Depression is a mood disorder characterized by persistent low mood, loss of interest, impaired functioning, and increased risk of self-harm. In acute care settings, priority nursing actions include ensuring safety, especially monitoring for suicidal ideation, and providing supportive therapeutic communication. Sleep disturbances are also a common physiologic manifestation of depressive disorders.

Rationale for correct choices:

• Major depressive disorder: The client demonstrates classic features of major depressive disorder, including flat affect, poor hygiene, social withdrawal, and expressions of hopelessness. The statement about life not being worth living strongly suggests depressive cognition and possible suicidal risk. Functional decline after job loss further supports a depressive episode. Alcohol use may exacerbate depressive symptoms but does not explain the overall presentation alone.

• Remain in the room with the client: Remaining with the client is a safety intervention that helps reduce the risk of self-harm, especially given the verbalization of hopelessness. Continuous presence allows the nurse to observe for escalating suicidal ideation or impulsive behavior. It also provides emotional support and reassurance in a controlled environment. This is a priority for clients at risk of self-directed harm.

• Assist the client to identify stressors: Helping the client identify stressors promotes therapeutic communication and encourages expression of emotions. The client has significant psychosocial stressors such as job loss and possible alcohol misuse. Exploring these stressors helps guide coping strategies and future interventions. This is an appropriate early step in psychiatric nursing care.

• Suicidal ideation: Suicidal ideation is a critical parameter to monitor in clients with major depressive disorder. The client has already expressed passive death wishes (“life is not worth living”), which places them at high risk. Ongoing assessment helps determine escalation toward active suicidal intent. Monitoring is essential for immediate safety planning and intervention.

• Sleep patterns: Sleep disturbance is a common physiological symptom of depression, often presenting as insomnia or hypersomnia. Monitoring sleep patterns helps evaluate severity and response to treatment. Depression-related fatigue and low energy are closely linked to disrupted sleep cycles. Tracking sleep also assists in measuring overall improvement.

Rationale for incorrect choices:

• Schizophrenia: Schizophrenia typically presents with positive symptoms such as hallucinations, delusions, disorganized speech, and impaired reality testing. This client does not demonstrate perceptual disturbances or thought disorganization. Instead, the presentation is centered on depressed mood, hopelessness, and functional decline following a psychosocial stressor. The absence of psychotic features makes schizophrenia an unlikely diagnosis.

• Dementia: Dementia is a progressive neurocognitive disorder characterized by gradual memory loss, impaired judgment, language difficulties, and decline in executive function over time. This client’s cognitive function is not described as impaired, and there is no evidence of progressive memory loss or disorientation. The onset of symptoms is linked to psychosocial stress and alcohol use rather than neurodegeneration.

• Dependent personality disorder: Dependent personality disorder involves pervasive excessive need to be taken care of, leading to submissive and clinging behavior. Clients typically struggle with decision-making and fear separation, often relying heavily on others for reassurance. This client instead demonstrates withdrawal, flat affect, and hopelessness rather than dependency-seeking behavior.

• Encourage client to eat slowly: This intervention is related to clients with swallowing difficulties or gastrointestinal issues, not depression. The client’s primary concern is mood disturbance and safety rather than nutritional intake behavior. There is no evidence of dysphagia or eating disorder requiring this instruction. Therefore, it is not relevant to the current condition.

• Determine client’s level of orientation: Orientation assessment is more relevant in conditions such as delirium or dementia rather than major depressive disorder. This client is alert and able to communicate logically, even though affect is flat. Cognitive disorientation is not a primary feature here. Therefore, this is not a priority intervention.

• Speak with the client using simple words: While clear communication is always beneficial, using overly simplified language is not necessary for a cognitively intact client with depression. The client does not show evidence of intellectual impairment or confusion. Therapeutic communication, not simplification, is the priority. Therefore, this intervention is not essential.

• Wandering at night: Wandering is primarily associated with dementia-related cognitive decline, not depression. There is no indication of cognitive impairment or disorientation in this client. The client’s symptoms are mood-related rather than neurodegenerative. Therefore, this parameter is not relevant.

• Panic attacks: Panic attacks are characteristic of anxiety disorders rather than major depressive disorder. The client’s presentation is consistent with persistent low mood and hopelessness rather than acute episodic fear. There are no reported symptoms of panic such as palpitations or sudden intense fear.

• Hallucinations: Hallucinations are associated with psychotic disorders or severe mood disorders with psychotic features, which are not evidenced in this case. The client demonstrates depressive symptoms without perceptual disturbances. There are no reports of sensory misinterpretations or delusions. Therefore, hallucinations are not a relevant monitoring parameter.