When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.

Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.

Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.

Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.

Choice A reason: This is incorrect because education about mastoidectomy is not relevant for a client with an upper respiratory infection. Mastoidectomy is a surgical procedure that removes part or all of the mastoid bone behind the ear, which can become infected or inflamed due to chronic or recurrent middle ear infections. The nurse should assess
the client's ear for signs of mastoiditis, such as swelling, tenderness, or redness behind the ear, but mastoidectomy is not a common or first-line treatment for upper respiratory infection.
Choice B reason: This is incorrect because a referral for a hearing test is not necessary for a client with an upper respiratory infection. Hearing test is a diagnostic tool that measures how well a person can hear different sounds at different frequencies and intensities. The nurse should ask the client about any changes in hearing or tinnitus, which are possible complications of upper respiratory infection, but a hearing test is not a routine or urgent intervention for this condition.
Choice C reason: This is correct because education on the administration of oral antibiotics can help treat an upper respiratory infection. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Upper respiratory infections can be caused by various pathogens, such as viruses, bacteria, or fungi, but bacterial infections are more likely to cause fever, otalgia, or purulent nasal drainage. The nurse should instruct the client on how to take antibiotics as prescribed, such as dosage, frequency, duration, side effects, and interactions.
Choice D reason: This is incorrect because a prescription for an antifungal cream is not appropriate for a client with an upper respiratory infection. Antifungal cream is a topical medication that kills or inhibits fungi that cause skin infections. Upper respiratory infection is not a skin infection, but an infection of the nose, throat, or sinuses. Antifungal cream has no effect on upper respiratory infection and may cause adverse effects or resistance.