A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel.
Which of the following statements should the nurse include in the discussion?
We will keep the client's fluid intake restricted until he is free of pain.
Expect the stoma to appear pale until healing is complete.
We need to check the client's urine output every hour.
Expect the diet’s urine to contain clots for the first 24 hours.
The Correct Answer is C
Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.
Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.
Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.
Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
Preschool-aged children (around 3 to 5 years old) have a limited understanding of death compared to older children or adults. They may not fully grasp the finality and permanence of death. They often have a more concrete and literal understanding of death.
A. Believing the death is punishment for bad behavior: Preschool-aged children (typically 3 to 5 years old) often have magical thinking and may believe that their thoughts or actions can cause events to happen. They may think that the death of a parent is a punishment for something they did or thought, reflecting their egocentric view of the world.
B. Recognizing the parent will never wake up: This understanding is more commonly seen in older children who have a more mature grasp of death. Preschool-aged children may not fully comprehend that death is irreversible and permanent.
C. While preschoolers might ask questions about the funeral out of curiosity, this is not the primary way they process or react to the death of a loved one. Their questions are often more about trying to understand what is happening rather than a genuine curiosity about the specifics of the service.
D. Understanding that everyone dies eventually: While preschool-aged children may have some understanding that death is a natural part of life, their comprehension of its full implications is limited. They may not fully grasp the universality of death and its inevitability for all living beings.
Correct Answer is B
Explanation
The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.
Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.
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