24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

Correct Answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

Correct Answer: A

Rationale: The correct answer is 'Autonomy'. Autonomy refers to the patient's right to make their own decisions, which is being honored when a nurse signs a consent form. While beneficence (Choice D) is an important ethical principle that involves acting in the patient's best interest, it is not what is being primarily observed in this instance. Justice (Choice B) refers to fairness and equal treatment and is not specifically relevant to this scenario. Accountability (Choice C) pertains to being answerable for one's actions and decisions, but again, it is not the principle directly observed in this situation. Therefore, when a nurse signs a consent form, it is the principle of autonomy that is being observed.

Correct Answer: A

Rationale: The correct answer is Community Organizing. This involves engaging and mobilizing individuals in a community or group to take action for the mutual benefit or to solve common problems. The options 'Family Nursing Care Plan', 'Nursing Intervention', and 'Nursing Process' are incorrect as these terms refer to specific nursing practices and methods, not the broader action of mobilizing and engaging a community to solve its own problems. Moreover, the provided rationale does not match the original question and correct answer. It instead describes the proactive and preventative nature of nursing care, which is unrelated to the concept of community organizing.

Correct Answer: C

Rationale: Given Miss CEE's state of major depression and her expressed feelings of worthlessness ('Nobody wants me'), the nurse would most likely expect her to be placed on suicide precaution. This means that measures would be taken to ensure her safety and to prevent her from harming herself. While medications like neuroleptics (Choice A) and anxiolytics (Choice D) might be employed as part of her overall treatment, these medicines are primarily used for conditions like psychosis and anxiety respectively, not specifically for depression or suicidal ideation. A special diet (Choice B) may be part of a comprehensive treatment plan, but it is not as immediate or as directly related to her current emotional and psychological state as suicide precaution is.

Correct Answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

Correct Answer: B

Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.

Correct Answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

Correct Answer: B

Rationale: The correct answer is B, as it emphasizes the importance of hygiene in food handling, which is crucial to prevent the spread of germs and diseases. The other options do not address the root of the issue, which is the unhygienic handling of food. Option A avoids direct confrontation but does not educate the vendor on proper hygiene. Option C, although it suggests a hygienic method, may not be practical or available in all situations. Option D is an avoidance strategy rather than a way to address the problem.

Correct Answer: C

Rationale: A process recording typically includes a non-verbal narrative account (Choice A), an analysis and interpretation (Choice B), and a verbal narrative account (Choice D). These components help in providing a comprehensive assessment of a patient's condition and ensuring that interventions are appropriately targeted for optimized outcomes. An audio-visual recording (Choice C), while it can be a part of some data collection processes, is not typically included in a process recording, making it the correct answer.