Which of the following findings must be immediately reported to the primary healthcare provider?

Correct Answer: D

Rationale: A purple stoma suggests ischemia or necrosis, requiring immediate reporting. Red stoma , excoriation , and stool are manageable. Nurses, per NCLEX, prioritize critical changes, making D correct.

Correct Answer: B

Rationale: A primary nursing intervention for sleep-rest disorders is promoting a consistent sleep routine, which helps regulate the body's circadian rhythm and improve sleep quality. This includes maintaining regular bedtimes, creating a calming pre-sleep environment, and minimizing disruptions. Choice A, encouraging late-night activities, would worsen sleep difficulties by stimulating the patient when they should be winding down. Choice C, increasing caffeine intake, is counterproductive as caffeine is a stimulant that interferes with sleep onset and quality. Choice D, limiting fluid intake all day, is impractical and unrelated to sleep improvementwhile reducing fluids before bed might prevent nighttime awakenings, all-day restriction risks dehydration. Choice B is the best approach, as it addresses the root of many sleep-rest issues by fostering habits that support restorative sleep, a critical aspect of patient recovery and well-being.

Correct Answer: B

Rationale: Assessing comfort in a nonverbal patient relies heavily on observing body language, such as facial expressions, posture, or movements, since they can't verbally express pain or distress. Grimacing, restlessness, or guarding an area signal discomfort, while relaxed features or calm breathing suggest ease. Choice A, asking direct questions, is ineffective for nonverbal patients who can't respond, like those with dementia or intubation. Choice C, relying on family reports only, is limitingwhile family input helps, it's subjective and incomplete without direct observation, as they may misinterpret or miss cues. Choice D, ignoring subtle cues, is negligent, as these are critical indicators in the absence of speech. Choice B is the best approach, aligning with nursing skills in nonverbal communication, ensuring a holistic comfort assessment by interpreting physical signs alongside vital signs or context, vital for tailoring care to silent patients' needs.

Correct Answer: B

Rationale: The nurse expects a client with chronic cancer pain to be a candidate for patient-controlled analgesia (PCA), as PCA allows self-administration of opioids within safe limits, ideal for managing persistent, severe pain common in cancer. It empowers alert clients to control pain flare-ups, enhancing comfort. Choice A, a confused client, isn't suitablePCA requires cognitive clarity to operate safely, preventing overdose. Choice C, a client unable to push a button, can't use PCA due to physical limitation, needing alternative delivery like IV drips. Choice D, a client with drug addiction history, may be excluded due to misuse risk, though not absoluteit depends on oversight, but cancer pain trumps this concern typically. Choice B is correct, reflecting PCA's design for coherent, pain-afflicted clients, aligning with nursing goals to optimize pain relief in chronic conditions like cancer, where fluctuating pain needs responsive management.

Correct Answer: B

Rationale: The nurse concludes the pain is chronic because it lasts longer than 6 months, a defining criterion distinguishing it from acute pain, which resolves quicker. Chronic pain persists beyond healing, often without clear cause, impacting life long-term. Choice A, sudden onset, suggests acute pain, tied to abrupt events like trauma, not chronic's gradual or sustained nature. Choice C, association with a specific injury, fits acute pain initially; chronic pain may start there but lingers beyond recovery. Choice D, immediate relief with medication, aligns with acute pain's responsivenesschronic pain often resists full relief. Choice B is correct, reflecting clinical standards nurses use to classify pain, prompting strategies like multimodal therapy or coping support, distinct from acute pain's short-term fixes.