A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

I should change my stoma pouch 30 minutes after meals.

I should cut my pouch opening 1/8 inch larger than my stoma.

I should clean my stoma with moisturizing soap.

I should expect my stoma to be blistered.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the stoma pouch 30 minutes after meals is not recommended, as meal timing does not dictate pouch changes. Pouches are typically changed every 3-7 days or if leaking, to prevent skin irritation. This statement reflects a misunderstanding, as it suggests an incorrect schedule unrelated to stoma care needs.
Choice B reason: Cutting the pouch opening 1/8 inch larger than the stoma ensures a snug fit, preventing leakage while protecting peristomal skin from irritation by digestive enzymes. Proper sizing maintains skin integrity and pouch adherence, supporting effective ostomy management. This statement demonstrates correct understanding of stoma care techniques.
Choice C reason: Cleaning the stoma with moisturizing soap is incorrect, as soaps with oils or fragrances can irritate peristomal skin and impair pouch adhesion. Mild, non-residue soap and water are recommended to maintain skin integrity. This statement indicates a misunderstanding of proper stoma cleaning practices.
Choice D reason: Expecting the stoma to be blistered is incorrect, as a healthy stoma should be pink, moist, and free of irritation. Blistering indicates complications like infection or poor pouch fit. This statement reflects a misunderstanding of normal stoma appearance and care, suggesting potential issues requiring intervention.

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Correct Answer is C

Explanation

Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.

A. A client who describes having persistent feelings of anger about the hurricane. B. A client who expresses a realization that life will not return to the way it was before the hurricane. C. A client who moved to an apartment located on higher ground than her previous home. D. A client who has frequent nightmares about the hurricane. E. A client who describes feeling disconnected from those around him following the hurricane.

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: Persistent anger about the hurricane is a PTSD symptom, reflecting emotional dysregulation and hyperarousal post-trauma. This ongoing distress, per DSM-5 criteria, warrants referral for mental health evaluation to address potential PTSD, making it a correct indicator for intervention.
Choice B reason: Realizing life will not return to normal is a realistic adjustment, not necessarily a PTSD symptom. Without additional distress indicators, this does not meet diagnostic criteria for PTSD, making it incorrect for requiring a referral in this context.
Choice C reason: Moving to higher ground is a practical response to reduce future risk, not a PTSD symptom. It reflects adaptive coping rather than psychological distress, so it does not warrant a referral for PTSD assessment, making it incorrect.
Choice D reason: Frequent nightmares about the hurricane are a hallmark PTSD symptom, classified as intrusive re-experiencing per DSM-5. This significant distress disrupts sleep and daily functioning, necessitating a referral for mental health evaluation, making it a correct choice.
Choice E reason: Feeling disconnected from others indicates emotional numbing, a PTSD avoidance symptom per DSM-5. This social withdrawal post-hurricane suggests significant psychological impact, warranting a referral for PTSD assessment to address underlying trauma, making it correct.

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A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?

Correct Answer is C

Explanation

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of post-traumatic stress disorder? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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