The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

The skin under the appliance looks red briefly after removing the appliance.

The stoma color is a deep red-purple.

An ascending colostomy delivers liquid feces.

The stoma extends 1/2 inch above the abdomen.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.

Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.

Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.

Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.

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

Explanation

Choice A rationale: This is a condition where the skin of the breast becomes dimpled and resembles an orange peel. It is caused by blockage of the lymphatic vessels by cancer cells or inflammation.

Choice B rationale: This is a condition where the skin of the breast breaks down and forms an open sore. It can be a sign of advanced or inflammatory breast cancer.

Choice C rationale: This is a condition where the nipple becomes inverted or pulled inward. It can be caused by scarring, infection, or cancer in the breast tissue or ducts.

Choice D rationale: These are lymph nodes in the armpit that are enlarged and hard but not painful. They can be a sign of cancer spreading from the breast to the lymphatic system.

Choice E rationale: This is a lump in the breast that can be felt and moved around. It is located at the upper outer quadrant of the right breast, as if looking at a clock face. It can be benign or malignant, depending on its size, shape, consistency, and borders.

Choice F rationale: Dense breast tissue is not an abnormal finding that indicates possible breast cancer. It is a normal variation that makes it harder to detect lumps or

abnormalities on mammograms. Women with dense breasts may need additional screening tests such as ultrasound or MRI.

A. The client's forearm spasms when a blood pressure cuff is inflated on the upper arm. B. The client complains of pain when his knee is extended with his hip flexed. C. The client feels pain in the calf when his foot is dorsiflexed. D. The client has a stiff neck when the neck is flexed towards the chest.

Correct Answer is B

Explanation

Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.

Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.

Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.

Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.

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The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

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

Explanation

A client is brought to the emergency department due to vomiting, fever, and a severe headache. The physician suspects meningitis; then assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig's sign when:

Correct Answer is B

Explanation

ADH release from the posterior pituitary is stimulated by which process?

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