When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?
A) The stoma is pink.
B) The stoma has a small amount of bleeding.
C) The stoma is prolapsed.
D) The stoma is on the abdominal surface.
Ans: C
Feedback:
If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.
You might also like to view...
If psychiatric nurses used Orem's theory for structuring much of their nursing practice, a major focus area for assessment would be the client's ability to do which of the following?
1. Adapt and function to meet various role expectations. 2. Care about self and participate in self-healing. 3. Implement self-care to meet psychosocial needs. 4. Enter into a therapeutic one-to-one relationship with the nurse.
When explaining what is occurring when their child has an acute bronchial asthma attack, the nurse will emphasize that which mediator is primarily responsible for the bronchial constriction?
A) Tree pollen B) Mold dust C) Histamine D) T-lymphocyte proliferation
A nurse is teaching a class to a group of newly diagnosed patients with type 1 diabetes. The discussion today is on the effect of diet and exercise as it relates to blood sugar. What is this intervention an example of?
A) Psychosocial caring B) Coping enhancement C) Genetic counseling D) Decision-making support
The home-care nurse determines that their patient is at risk for further injury due to normal aging sensation loss when they state the following:
1. "I have this large red mark on my arm and I think it occurred yesterday from cooking." 2. "I can't remember what I ate for lunch yesterday." 3. "I got a small cut on my arm from a zipper when I was getting dressed yesterday." 4. "I have some discolorations on my arm, but they have been there for months."