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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.
Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.
Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.
Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.
Correct Answer is B
Explanation
Choice A rationale:
Injecting additional insulin before exercising is not a recommended practice for individuals with type 1 diabetes mellitus. It can lead to hypoglycemia (low blood sugar) during exercise. The goal is to ensure that blood glucose levels are within a safe range before starting physical activity.
Choice B rationale:
Eating a piece of fruit before exercising is a suitable recommendation for someone with type 1 diabetes mellitus. Consuming a source of carbohydrates, such as fruit, can help prevent hypoglycemia during exercise. Carbohydrates provide a steady source of glucose for energy.
Choice C rationale:
Exercising when insulin is at its peak action can be risky for individuals with type 1 diabetes. At this time, the risk of hypoglycemia is higher because insulin is actively lowering blood sugar levels. It is generally recommended to exercise when insulin is at a moderate or lower level of activity to reduce the risk of hypoglycemia.
Choice D rationale:
Avoiding protein before exercising is not a specific recommendation for individuals with type 1 diabetes mellitus. While protein does not directly impact blood glucose levels as carbohydrates do, it is an essential nutrient for overall health. A balanced meal or snack that includes carbohydrates and protein is typically a better choice before exercise.
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