A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance?
"I will attend a support group to help me handle difficulties when they occur."
"I have my partner empty the bag for me, so I don't have to look at it."
"I look forward to having normal bowel movements again."
"I wish my sexual relationship with my partner was like it was before."
The Correct Answer is A
The correct answer is choice A, "I will attend a support group to help me handle difficulties when they occur." This statement indicates that the client is accepting the situation and taking proactive steps to manage any difficulties that may arise. Choice B is incorrect because relying on someone else to empty the bag suggests possible denial or avoidance of the situation. Choice C is incorrect because normal bowel movements after an ileostomy may not happen. Choice D is incorrect because it is not related to acceptance of the ileostomy. Choice B is not correct because it shows possible denial or avoidance of the situation. Choice C is not correct because normal bowel movements may not occur. Choice D is not correct because it is not related to acceptance of the ileostomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is A
Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
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