An expected assessment finding for an enterostomy is:
A. A moist, reddish-pink stoma
B. A dry, purplish stoma
C. Erythema on the skin around the stoma
D. No blood noted from the stoma when washed
A
A. Stoma is moist and reddish pink. Skin is intact and free of irritation.
B. Necrotic stoma is manifested by purple or black color, dry instead of moist texture.
C. Skin is intact and free of irritation.
D. Assess circulation to stoma. Necrotic stoma is manifested by failure to bleed when washed gently or by presence of tissue sloughing.
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The parents of a child born with severe hypoplastic left heart syndrome ask the nurse about treatment options. Which option is inconsistent with the nurse's knowledge about this condition?
A. "Palliative or end-of-life care is one possibility." B. "She can be listed for a cardiac transplant." C. "Surgical correction involves several procedures." D. "We can give a series of dopamine (Intropin) infusions."
The client is being admitted to the mental health unit because he is convinced that he is dying, despite normal test and examination results. He complains of fatigue, an inability to eat, severe loneliness, and episodes of shortness of breath
The first priority in helping the client is his 1. inability to eat. 2. social isolation. 3. shortness of breath. 4. complaints of fatigue.
The nurse is performing a rapid assessment for each of the following clients. Which of the following clients require immediate medical assistance? Standard Text: Select all that apply
1. The client is pale and is breathing in a shallow manner. 2. The client's oxygen saturation level is 74% and is dyspneic. 3. The client is rating his pain at a 3 out of a 10 on a pain scale. 4. The client is unable to follow directions. 5. The nurse determines that the client's level of consciousness is decreasing.
The clinic nurse observes the Reed family, which includes a woman and her sister who live together. They are trying to support one another and provide extended care to their mother who has recently been diagnosed with Alzheimer's disease
The two sisters describe their supportive experience with a homemaker who visits their home twice a week to help with bathing their mother. They say she is "humorous, and cheerful", and absorbs their mother's attention for the whole time she is present. This is a positive description of: A) Triangulation B) Family relationship building C) Family rituals D) Communication