The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is moist.
c. Stool is discharging from the stoma.
d. Stoma is purple.
D
A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.
You might also like to view...
The client with diabetes mellitus reports having difficulty trimming the toenails because they are thick and ingrown. What should the nurse recommend to this client?
A) Make an appointment with a podiatrist. B) Offer to file the tops of the nails to reduce thickness after cutting. C) Cut the nails straight across with a clipper after the bath. D) Make an appointment with a nail shop for a pedicure.
A client comes to the reproductive health clinic and reports that she woke up in a strange room this morning, that her perineal area is sore, and she can't clearly remember what happened the previous evening
The client says that she is afraid that she was a victim of a drug-facilitated sexual assault. Which statement should the nurse include when discussing this possibility with the client? A. "Drinking alcohol can lead to uninhibited sexual behavior, which is not the same as rape." B. "Some men use drugs mixed into a drink to subdue a potential victim prior to a rape." C. "It is rare that a woman doesn't remember what happened if she were actually raped." D. "We need to check for forensic evidence of rape before we can be sure what happened."
A nurse determines that a patient is able to follow directions but appears to experience a narrowed perceptual field and focus on immediate concerns. The nurse determines that the patient is experiencing anxiety at which level?
a. Mild b. Moderate c. Severe d. Panic
A patient has been on oral corticosteroids to decrease the symptoms of chronic obstructive pulmonary disease. What is the patient at risk for developing?
A) Osteoporosis B) Osteoarthritis C) Oat cell carcinoma D) Pulmonary fibrosis