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.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attending a support group to seek help and guidance for handling difficulties indicates the client's acceptance of having a new ileostomy. It demonstrates a proactive approach to coping with the challenges associated with living with an ileostomy.

Choice B rationale:

Having a partner empty the bag for the client to avoid looking at it may indicate avoidance or denial rather than acceptance. While support from a partner is essential, it's also important for the client to actively participate in self-care and adaptation.

Choice C rationale:

Looking forward to having normal bowel movements again may indicate a lack of acceptance or unrealistic expectations since having an ileostomy means a change in bowel function. The client should be educated about the permanence of the ileostomy.

Choice D rationale:

Wishing for a return to the pre-ileostomy sexual relationship may indicate difficulty accepting the changes in body image and function that come with an ileostomy. It may also suggest unrealistic expectations. The client should be encouraged to seek support and counseling for body image issues and sexual concerns.

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Correct Answer is B

Explanation

Choice A rationale:

"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.

Choice B rationale:

"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.

Choice C rationale:

"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.

Choice D rationale:

"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.

A. Monitor for muscle paralysis. B. Place in contact isolation. C. Check for increased salivation. D. Administer clindamycin hydrochloride.

Correct Answer is A

Explanation

Choice A rationale:

Monitoring for muscle paralysis is crucial in botulism poisoning because it is a characteristic symptom of the condition. Botulinum toxin causes muscle weakness and paralysis, which can lead to respiratory distress. Monitoring for these symptoms allows for timely intervention.

Choice B rationale:

Placing the client in contact isolation is not a priority in botulism poisoning. Botulism is not typically transmitted from person to person, so isolation is not necessary. The focus should be on monitoring and supportive care.

Choice C rationale:

Checking for increased salivation is important because excessive salivation is a symptom of botulism poisoning. However, monitoring for muscle paralysis is more critical as it can lead to respiratory compromise.

Choice D rationale:

Administering clindamycin hydrochloride is not a standard treatment for botulism poisoning. The primary treatment involves supportive care and, in some cases, the administration of antitoxin if available.

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A nurse is evaluating a client's acceptance of having a new ileostomy.Which of the following statements by the client indicates acceptance?

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A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?