A nurse is caring for a client who has a newly created colostomy. The client’s partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?
Suggest the client join a support group for people who have colostomies.
Encourage the client and partner to avoid expressing negative feelings about the colostomy.
Instruct the client’s partner to assume care of the colostomy for the client.
Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.
The Correct Answer is A
Choice A reason: Suggesting a support group helps the client address emotional resistance to the colostomy through peer support. This fosters psychological adjustment, reduces stigma, and promotes self-management by sharing experiences, aligning with evidence-based strategies to improve coping and adaptation in clients with new ostomies.
Choice B reason: Encouraging avoidance of negative feelings dismisses the client’s emotional response, hindering psychological adaptation. Accepting a colostomy requires processing grief and fear. Suppressing emotions delays coping, as psychological adjustment involves acknowledging feelings to integrate the stoma into the client’s self-image effectively.
Choice C reason: Instructing the partner to assume colostomy care undermines the client’s autonomy and delays self-management. Independence in stoma care is critical for psychological and practical adaptation. Dependency may hinder adjustment, as clients need to develop skills to manage their condition independently.
Choice D reason: Transferring to a rehabilitation facility is premature without trying in-hospital education or support groups. Most clients learn stoma care with nursing guidance. Transfer disrupts care continuity and may increase distress, failing to address emotional resistance directly, unlike peer support interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.
Correct Answer is C
Explanation
Choice A reason: Occasional mild nausea is common in early pregnancy due to hormonal changes and does not typically require reporting unless severe or persistent. It is not a concerning finding at 14 weeks, so this is incorrect for urgent reporting.
Choice B reason: Mild ankle swelling in the evening can be normal due to fluid retention but is not urgent unless accompanied by other preeclampsia signs. It is less critical than bleeding, so this is incorrect for priority reporting.
Choice C reason: Vaginal bleeding at 14 weeks is abnormal and may indicate miscarriage, placental issues, or other complications, requiring immediate reporting to the provider for evaluation. This finding is critical at 14 weeks gestation, aligning with obstetric emergency protocols, making it the correct choice for teaching.
Choice D reason: Increased appetite is normal in pregnancy as nutritional needs rise and does not warrant urgent reporting. It reflects healthy adaptation rather than a complication, so this is incorrect for inclusion in teaching about concerning findings.
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