A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?
"You should scrub the skin around the colostomy when cleaning."
"You can use an adhesive remover when changing the colostomy skin barrier."
"You will need a device to suction stool from the colostomy bag."
"You should empty the colostomy bag when it is three-fourths full."
The Correct Answer is B
b. "You can use an adhesive remover when changing the colostomy skin barrier."
The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.
Explanation for the other options:
a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.
c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.
d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.
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Correct Answer is C
Explanation
c. Instruct the client to use abdominal breathing.
When a client is experiencing a panic atack, the nurse's first priority is to help the client manage their symptoms and provide immediate relief. Instructing the client to use abdominal breathing is the most appropriate initial intervention.
Explanation for the other options:
a. Discuss the client's feelings prior to the panic atack. While discussing the client's feelings can be beneficial in addressing the underlying causes of anxiety, it may not be the most effective immediate intervention during a panic atack. The client's focus during a panic atack is typically on managing the physical symptoms and regaining control.
b. Encourage the use of positive self-talk strategies. Positive self-talk can be helpful in managing anxiety in general, but during a panic atack, the individual may have difficulty engaging in positive self-talk due to the intensity of symptoms. Addressing the immediate physical symptoms is a priority before exploring coping strategies.
d. Administer an anti-anxiety medication. Medication administration may be necessary in some cases, but it is not the first-line intervention for managing a panic atack. Non-pharmacological interventions, such as breathing techniques, should be implemented first. If the panic atack persists or worsens despite these interventions, medication may be considered.
In summary, during a panic atack, the immediate focus should be on helping the client manage their symptoms. Instructing the client to use abdominal breathing can help promote relaxation and reduce the intensity of the panic atack.
Correct Answer is B
Explanation
To effectively communicate with a client who speaks a different language, it is important to use alternative methods of communication. One effective method is to supplement spoken language with pictures or visual aids. This can help bridge the language barrier and enhance understanding between the nurse and the client.
Recognize that the client nodding indicates an understanding of the information: Nodding does not always indicate understanding. It could be a cultural gesture or a sign of politeness. Relying solely on nodding may lead to miscommunication and misunderstanding.
Speak to the client at an increased volume: Speaking louder does not necessarily overcome the language barrier. It may make communication more difficult and could be perceived as rude or intimidating.
Ask a family member of the client to interpret: While involving a family member may seem helpful, it is not always reliable or appropriate. Family members may not be proficient in both languages or may not fully understand medical terminology. Additionally, the client may desire privacy or may not want to burden their family members with the responsibility of interpretation.
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