A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

I will irrigate the colostomy every day.

I will notify my doctor if the stoma starts to look purple.

I will no longer be able to eat nuts.

I should expect my stool to be formed.

Answer and Explanation

The Correct Answer is B

I will notify my doctor if the stoma starts to look purple

The comment by the client indicating an understanding of the teaching is option B: "I will notify my doctor if the stoma starts to look purple."

I will irrigate the colostomy every day in (option A) is incorrect. Colostomy irrigation is not necessary for all clients with an ascending colostomy. It is important to individualize the teaching based on the client's specific needs and healthcare provider's instructions. Routine colostomy irrigation may not be required, and the client should follow the healthcare provider's guidance regarding colostomy care.

I will no longer be able to eat nuts in (option C) is incorrect. There are generally no dietary restrictions for clients with an ascending colostomy, unless otherwise advised by their healthcare provider. It is important to provide accurate information about dietary considerations, which may vary based on individual circumstances and healthcare provider recommendations.

I should expect my stool to be formed in (option D) is incorrect. With an ascending colostomy, the stool is typically liquid or semi-liquid as it comes from the ascending colon, which is higher in the gastrointestinal tract. The stool is not expected to be formed. It is important for the client to have appropriate expectations regarding stool consistency to manage their colostomy effectively.

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Correct Answer is B

Explanation

The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel toward the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.

"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.

"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.

"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.

A. Posterior fontanel closed B. Rolls from back to abdomen C. Anterior fontanel closed D. Moves objects to mouth

Correct Answer is C

Explanation

Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.
The other findings mentioned are typical developmental milestones for a 4-month-old infant:
1. Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
2. Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.

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A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

Correct Answer is B

Explanation

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

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