The nurse is providing care for a client with a newly created colostomy. Which nursing diagnosis should receive priority during the client's first week post-op?

Correct Answer: B

Rationale: Disturbed body image is the priority in the first week post-colostomy, as clients adjust to altered appearance infection, fluids, and nutrition are managed but less immediate emotionally. Nurses support coping, teaching stoma care, aiding psychological adaptation early on.

Correct Answer: C

Rationale: Cutting food and encouraging self-feeding leverages the client's unaffected left side post-CVA, promoting independence puree isn't needed unless swallowing's impaired, left-side tray placement helps, and quick feeding risks aspiration. Nurses support autonomy, enhancing dignity in stroke recovery.

Correct Answer: B

Rationale: Bright red blood in IV tubing indicates its oxygen-rich source. Capillary blood (choice A) is a mix of arterial and venous, not typically seen in IV backflow. Arterial blood (choice B), bright red due to high oxygenation, suggests the IV catheter has pierced an artery, a rare but serious complication. Venous blood (choice C) is darker, deoxygenated, and typical in veins, not matching the description. Peripheral blood (choice D) is vague, encompassing all types. B is correct, as arterial puncture explains the color and urgency. Nurses must stop infusion, apply pressure, and seek medical review to manage this vascular injury.

Correct Answer: A

Rationale: Kramer's rule assesses neonatal jaundice by observing skin yellowing progression. From head (zone 1) to feet (zone 5), it correlates with bilirubin levels (e.g., zone 3 ≈ 10-15 mg/dL), guiding intervention. Necrotizing enterocolitis (choice B) uses imaging/labs, not this rule. Burns (choice C) rely on burn percentage rules (e.g., Lund-Browder). Asphyxia (choice D) involves Apgar/gas analysis. A is correct, specific to jaundice. Nurses apply it, monitor bilirubin, and initiate phototherapy, preventing kernicterus.

Correct Answer: A

Rationale: The first manifestation of inflammation is redness (A), caused by vasodilation increasing blood flow to the injury site immediately after transient vasoconstriction. Swelling (B) follows as capillary permeability rises, leaking fluid into tissues. Pain (C) emerges from pressure on nerves and chemical mediators, a later effect. Increased heat (D) accompanies redness but isn't the initial sign; it's a byproduct of enhanced circulation. Redness appears earliest in the vascular phase, observable before edema or pain develops, aligning with inflammation's sequence and making A the correct answer.