During a home health visit, a client recovering from a recent permanent colostomy creation refuses to look at the surgical site. The client tells the practical nurse, "My spouse can handle the bags for now. I'll take over once my intestines heal and they reverse this thing." The spouse privately states they are exhausted from managing the care alone. Which nursing actions are appropriate? (Select all that apply)
- Document the specific statements demonstrating the client's use of denial.Answer
- BReassure the client that feeling hesitant is common but they will eventually get used to the appliance.
- Notify the supervising registered nurse about the spouse's caregiver role strain.Answer
- DEncourage the client to look at the stoma for a few seconds today to begin the acceptance process.
- Explore the spouse's current coping strategies and available support systems.Answer
- FRevise the nursing care plan to include daily cognitive restructuring interventions for body image disturbance.
Answer
The correct actions are to document the client's statements demonstrating denial, notify the registered nurse about the spouse's strain, and explore the spouse's current coping strategies.
The correct nursing actions align with the practical nurse's role in data collection, therapeutic communication, and interdisciplinary collaboration. Accurately documenting the client's statements provides objective evidence of denial, a common initial coping mechanism for profound loss or body image changes. Exploring the spouse's coping strategies constitutes appropriate psychosocial data collection, and notifying the supervising registered nurse ensures the overarching care plan can be updated to address the emerging caregiver strain safely.
Step-by-Step Solution
Key Concept
Supporting adaptive coping mechanisms and recognizing denial while operating within the practical nursing scope of practice.