A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. "Remain on bed rest for 24 hours following the procedure." Prolonged bed rest increases the risk of venous thromboembolism (VTE) and pulmonary complications. Early ambulation or movement is encouraged to promote circulation and prevent complications.
B. "Participate in range-of-motion exercises." Range-of-motion (ROM) exercises help stimulate venous return, improve circulation, and prevent blood stasis, which lowers the risk of postoperative blood clots and muscle stiffness.
C. "Place a pillow under your knees while in bed." Placing a pillow under the knees can impair circulation and increase the risk of venous stasis and thrombus formation. It is not recommended for circulation promotion.
D. "Use an incentive spirometer every 4 hours." While this instruction helps prevent respiratory complications, it is not a direct intervention for improving circulatory function. It's primarily used to promote lung expansion postoperatively.