The nurse observes the stoma to be red and edematous. Based on this finding, what should the nurse do?

Correct Answer: B

Rationale: The correct answer is B) Record the findings. In this scenario, a red and edematous stoma is a common post-operative finding and not indicative of an immediate complication. It is crucial for the nurse to document these observations accurately to establish a baseline for the client's condition and to monitor for any changes over time. Option A) Immediately apply ice is incorrect because applying ice to a red and edematous stoma could potentially cause further damage or complications. It is not a standard intervention for this situation. Option C) Elevate the client's buttocks is incorrect because elevating the buttocks would not directly address the redness and edema of the stoma. It is not a relevant intervention in this context. Option D) Notify the primary healthcare provider is incorrect because, in this case, the observed redness and edema of the stoma are expected post-operative findings. There is no need for immediate notification unless there are additional concerning symptoms or changes in the client's condition. Educationally, understanding the rationale behind documenting normal post-operative findings is essential for nurses to differentiate between expected and unexpected outcomes. This skill is crucial in providing quality care, ensuring accurate communication with the healthcare team, and promoting optimal client outcomes. By recording these findings, nurses can track trends, identify deviations from the norm, and intervene promptly when necessary.

Correct Answer: B

Rationale: Fibromyalgia is a chronic condition marked by widespread musculoskeletal pain, often accompanied by fatigue, sleep disturbances, and cognitive difficulties known as 'fibro fog.' This pain is typically diffuse, affecting multiple body areas, and is a hallmark symptom distinguishing it from other disorders. Choice A, improved energy levels, is incorrect because fibromyalgia commonly causes debilitating fatigue, not vitality. Choice C, temporary muscle stiffness, doesn't capture the persistent, widespread nature of fibromyalgia painstiffness may occur, but it's not the defining feature. Choice D, increased cognitive clarity, is the opposite of the memory and concentration issues patients experience. Choice B correctly identifies widespread musculoskeletal pain as a common, central symptom, making it a key focus for nursing assessment and management in affected individuals.

Correct Answer: B

Rationale: A quiet, dark environment best promotes rest in patients by minimizing sensory stimulation, allowing the body and mind to relax and enter a restorative state. Darkness supports melatonin production, aiding sleep, while quietness reduces arousal, key for those with sleep-rest disorders or fatigue. Choice A, bright lighting, disrupts rest by suppressing melatonin and signaling wakefulness, often used to keep patients alert, not relaxed. Choice C, frequent interruptions, fragments rest, preventing deep sleep or recovery, a common issue in busy hospital settings. Choice D, high noise levels, stimulates the nervous system, increasing stress and hindering rest, especially for sensitive patients. Choice B is the optimal answer, reflecting evidence-based nursing practices that create a conducive rest environment, essential for healing and comfort across various conditions.

Correct Answer: C

Rationale: The statement I only take my pain medication when I can't stand the pain anymore' indicates a need for further education, as it suggests the client delays medication until pain peaks, undermining chronic pain management. Effective control requires consistent dosing to maintain steady relief, preventing escalation that's harder to reverse. Choice A, taking medication as prescribed, shows adherence to a regimen, not a gap in understanding. Choice B, using relaxation techniques, reflects a proactive, educated approach to complement medication. Choice D, keeping a pain diary, demonstrates awareness and engagement in tracking pain patterns, aiding treatment adjustments. Choice C is correct, highlighting a misconceptionwaiting until pain is unbearable can increase suffering and medication needs. Nurses should educate on scheduled dosing, explaining how proactive management stabilizes pain levels, reduces flare-ups, and improves function, contrasting with reactive use that perpetuates a pain cycle.

Correct Answer: B

Rationale: The nurse's initial action is to assess the client's pain level, as chronic pain likely disrupts sleep via discomfort or stress, and understanding its intensity or pattern guides intervention. Assessment (e.g., 0-10 scale) identifies if pain control needs adjustment before adding sleep aids. Choice A, administering a sedative, risks masking pain or causing side effects without addressing the rootpain relief may suffice alone. Choice C, encouraging a warm bath, is a valid nonpharmacological option but premature without knowing pain's role; it might not help severe pain. Choice D, telling the client to relax, dismisses the issuerelaxation is hard with unmanaged pain. Choice B is correct, prioritizing assessment, a nursing fundamental, to pinpoint pain's impact on sleep, enabling targeted solutions like adjusting analgesics or adding sleep strategies, improving rest and overall well-being.