A client is 24 hours post-op after having a colon resection (part of the colon is removed and the healthy ends are sewn back together). His abdominal incision is dry and intact, but the nurse notes that bowel sounds have not returned. What condition is this client likely experiencing?
Paralytic ileus
Clostridium difficile colitis
Constipation
Fecal impaction
The Correct Answer is A
Choice A reason: This is the correct answer because paralytic ileus is a condition in which the intestinal motility is decreased or absent, resulting in the inability to pass gas or stool. It is a common complication of abdominal surgery, as the manipulation of the bowel can cause inflammation and nerve damage. The nurse should monitor the client for signs of bowel obstruction, such as abdominal distension, nausea, vomiting, and pain.
Choice B reason: This is not the correct answer because Clostridium difficile colitis is a condition in which the normal flora of the colon is disrupted by antibiotic therapy, allowing the overgrowth of a toxin-producing bacteria that causes inflammation and diarrhea. It is not a common complication of abdominal surgery, but rather a risk associated with prolonged hospitalization and antibiotic use.
Choice C reason: This is not the correct answer because constipation is a condition in which the stool is hard, dry, and difficult to pass. It is not a common complication of abdominal surgery, but rather a side effect of opioid analgesics, which can slow down the bowel movements. The nurse should encourage the client to increase fluid and fiber intake, and use stool softeners as prescribed.
Choice D reason: This is not the correct answer because fecal impaction is a condition in which a large mass of stool is stuck in the rectum, preventing the passage of gas or stool. It is not a common complication of abdominal surgery, but rather a result of chronic constipation, dehydration, or immobility. The nurse should assess the client for signs of impaction, such as abdominal cramping, rectal pressure, and leakage of liquid stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cognitive domain of learning involves the mental processes of acquiring, storing, and applying knowledge. It includes skills such as remembering, understanding, analyzing, and evaluating. An example of cognitive learning is the RN asking the client to explain the purpose and effects of his inhaler.
Choice B reason: Affective domain of learning involves the emotional aspects of learning, such as attitudes, values, beliefs, and feelings. It includes skills such as receiving, responding, valuing, and committing. An example of affective learning is the RN asking the client how he feels about using his inhaler.
Choice C reason: Psychomotor domain of learning involves the physical aspects of learning, such as movement, coordination, and manipulation. It includes skills such as imitating, practicing, adapting, and creating. An example of psychomotor learning is the RN asking the client to demonstrate proper use of his inhaler.
Choice D reason: Kinesthetic domain of learning is not a recognized domain of learning, but rather a learning style that refers to the preference of learning by doing or experiencing. Kinesthetic learners tend to learn best by engaging in physical activities, such as hands-on tasks, simulations, and experiments.
Correct Answer is A
Explanation
Choice A reason: Vitamin D is a fat-soluble vitamin that helps the body absorb calcium and phosphorus, which are essential for bone health. The main source of vitamin D is exposure to sunlight, which triggers the skin to produce it. The nurse should advise the client to spend at least 15 minutes outdoors every day, preferably in the morning or evening, when the sun is not too strong. The client should also wear sunscreen and protective clothing to prevent sunburn and skin damage.
Choice B reason: Reducing the amount of cereal in the diet is not a good recommendation for increasing vitamin D intake. Cereal is often fortified with vitamin D and other nutrients, such as iron and folic acid. The nurse should encourage the client to choose cereals that are high in vitamin D and low in sugar and fat. The client should also consume other foods that are rich in vitamin D, such as fatty fish, egg yolks, cheese, and mushrooms.
Choice C reason: Increasing intake of dietary calcium is important for preventing and treating osteoporosis, but it does not directly affect vitamin D intake. Calcium is a mineral that helps build and maintain strong bones and teeth. The nurse should recommend the client to consume foods that are high in calcium, such as dairy products, leafy greens, nuts, and tofu. The client should also take a calcium supplement if needed, as prescribed by the provider.
Choice D reason: Adding a regular exercise routine is beneficial for improving overall health and well-being, but it does not directly influence vitamin D intake. Exercise helps strengthen the muscles and bones, prevent falls and fractures, and reduce the risk of chronic diseases. The nurse should suggest the client to engage in moderate physical activity for at least 30 minutes a day, three times a week. The client should choose exercises that are appropriate for their age and fitness level, such as walking, swimming, or yoga.
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