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 D
Explanation
Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.
Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.
Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.
Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.
Correct Answer is C
Explanation
Choice A reason: William, who exercises three times a week, does not have a modifiable risk factor for osteoporosis. Exercise is actually beneficial for bone health, as it stimulates bone formation and reduces bone loss. Exercise also improves muscle strength, balance, and coordination, which can prevent falls and fractures.
Choice B reason: Samantha, who has a family history of osteoporosis, does not have a modifiable risk factor for osteoporosis. Family history is a genetic factor that cannot be changed or controlled. Having a parent or sibling with osteoporosis increases the risk of developing the condition, especially if they have had a fracture.
Choice C reason: Juanita, who smokes two packs of cigarettes a day, has a modifiable risk factor for osteoporosis. Smoking is a lifestyle factor that can be changed or controlled. Smoking increases the risk of osteoporosis by reducing the blood supply to the bones, decreasing the absorption of calcium, and lowering the levels of estrogen, which protects the bones.
Choice D reason: Tori, who is postmenopausal at age 40, does not have a modifiable risk factor for osteoporosis. Menopause is a natural process that occurs when the ovaries stop producing estrogen, which leads to bone loss and increased risk of fractures. Menopause cannot be prevented or reversed, but its effects on bone health can be managed with hormone therapy, calcium, and vitamin D supplements.
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