The nurse is instructing a client with a new colostomy on its care and notes that the stoma is large and dusky. The most appropriate nursing intervention at this time is to
a. assess the client's reaction to the ostomy site.
b. assist the client to irrigate the colostomy.
c. notify the surgeon immediately.
d. reassure the client that the stoma will decrease in size.
C
The nurse should assess the client's stoma closely. The stoma should be red and moist. If it be-comes dark or dusky, the nurse must report this to the surgeon immediately as this probably represents ischemia.
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A nurse is ordered to apply a transcutaneous electrical nerve stimulation (TENS) unit to a client recovering from abdominal surgery. Which of the following is a consideration when using this device?
A) TENS is an invasive technique for providing pain relief. B) TENS involves the electrical stimulation of large-diameter fibers to inhibit the transmission of painful impulses carried over small-diameter fibers. C) TENS is most beneficial when used to treat pain that is generalized. D) A TENS unit is applied intermittently throughout the day and should not be worn for extended periods of time.
The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression?
(Select all that apply.) 1. "My work environment would depress anyone." 2. "It seems like almost anything can make me cry." 3. "Being here away from my family makes me sad." 4. "I just can't seem to get excited about anything anymore." 5. "The family always thought that my father was depressed." 6. "I like winter because I can just cover up on the couch and sleep."
A home care nurse was caring for an elderly gentleman who lived with his son. The client kept falling asleep. Which action is most important for the nurse to take?
a. Call the physician and ask for a daytime stimulant. b. Check the medications for consistency between pills and prescribed doses. c. Suggest that the client get a TV to keep himself entertained. d. Suggest that the client sit up or even try to walk and then try to sleep at night.
The educator is discussing the symptoms of schizophrenia with a nurse. Which receptor site should the educator associate with the symptoms?
A. Dopamine type 2 B. Adrenergic C. Beta 2 D. Cholinergic