The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?

Correct Answer: A

Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.

Correct Answer: A

Rationale: Nursing theory serves as a foundational framework, guiding practice with clear goals. It provides knowledge and a rationale for client interventions, explaining why specific actions like wound care techniques benefit patients, rooted in conceptual understanding. It offers a rationale for appropriate nursing actions, ensuring responses to situations, such as pain management, are logical and effective. Identifying and defining concepts important to nursing like health or caring clarifies the discipline's focus, fostering consistency. Increasing the nursing body of knowledge expands its intellectual base through theoretical development. However, it doesn't provide a single definition for nursing, instead directing it toward a common purpose across diverse interpretations. These goals unify nursing, bridging theory to practice, and equip nurses to deliver informed, purposeful care that adapts to client needs and evolves with new insights.

Correct Answer: B

Rationale: Wellness is a dynamic balance of physical, psychological, social, and spiritual aspects, reflecting an active pursuit of optimal living like exercising, managing stress, connecting socially, and finding purpose. Health is a broader state of well-being, per WHO, not inherently dynamic. Holism is a care philosophy addressing all dimensions, not the state itself. Health promotion involves interventions to improve health, not the balance. Wellness captures an individual's journey toward harmony, as when a nurse helps a client integrate diet (physical), support groups (social), coping skills (psychological), and values (spiritual). This concept guides nursing to foster resilience and fulfillment, distinct from static health or care approaches, emphasizing personal agency in thriving.

Correct Answer: A

Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.

Correct Answer: D

Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.