A nurse is caring for a client who has a new colostomy and states they are not ready to look at the stoma. Which of the following teaching strategies is helpful and encourages the client to share their feelings about the colostomy?
Question-and-answer
Discussion
Role play
Return demonstration
The Correct Answer is B
Choice A reason: A question-and-answer session might provide information but does not specifically encourage the client to share their feelings and concerns about the colostomy. It's more about imparting knowledge rather than addressing emotional needs.
Choice B reason: Discussion is an effective strategy to encourage the client to share their feelings about the colostomy. It creates an open environment for expressing concerns, asking questions, and receiving emotional support.
Choice C reason: Role play can be useful in teaching new skills or preparing for specific situations, but it might not be the best initial approach for someone struggling to accept a new colostomy. Emotional readiness and comfort should be addressed first.
Choice D reason: Return demonstration is a method to confirm the client's understanding of a procedure by having them perform it. It is more appropriate for assessing practical skills rather than addressing emotional concerns and readiness to engage with the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hyperactive bowel sounds are not typically associated with peritonitis. Instead, peritonitis often leads to decreased or absent bowel sounds due to the inflammation and subsequent ileus (paralysis of the bowel), which slows down or halts peristalsis.
Choice B reason: Increased urinary output is not a common symptom of peritonitis. In fact, peritonitis can sometimes result in reduced urine output due to the body's response to infection and inflammation, which can affect kidney function.
Choice C reason: Frequent bowel movements are not characteristic of peritonitis. The inflammation in the peritoneal cavity often leads to bowel paralysis, resulting in decreased bowel movements rather than increased frequency.
Choice D reason: A rigid abdomen is a hallmark sign of peritonitis. The rigidity is due to the body's protective response to the severe inflammation in the peritoneal cavity, causing the abdominal muscles to tighten and become hard. This clinical sign, along with severe pain, can help healthcare providers diagnose peritonitis.
Correct Answer is D
Explanation
Choice A reason: Securing the drain to the client's bed sheet is not appropriate as it does not ensure the drain is properly secured and could lead to accidental dislodgement.
Choice B reason: Measuring the drainage every hour for the first 8 hours is not standard practice. Usually, drainage measurement frequency is less frequent unless there are specific clinical concerns.
Choice C reason: Removing the JP drain should be done according to medical orders, and typically the nurse would not make the decision independently. The JP drain is usually removed when the output decreases to a minimal level and the surgeon orders its removal.
Choice D reason: Expelling the air from the JP bulb after emptying is the correct action to re-establish suction, which is necessary for the drain to function effectively.
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