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: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.
Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.
Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.
Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.
Correct Answer is B
Explanation
Choice A reason: Hypernatremia is a condition of high sodium levels in the blood. It can cause symptoms such as thirst, dry mouth, confusion, agitation, and seizures. It is not likely to cause postural hypotension, which is a drop in blood pressure when changing positions.
Choice B reason: Hyponatremia is a condition of low sodium levels in the blood. It can cause symptoms such as headache, nausea, vomiting, muscle weakness, fatigue, and confusion. It can also cause postural hypotension, as sodium helps regulate fluid balance and blood pressure.
Choice C reason: Hyperkalemia is a condition of high potassium levels in the blood. It can cause symptoms such as muscle weakness, paralysis, irregular heartbeat, and cardiac arrest. It is not likely to cause postural hypotension, which is more related to fluid and sodium levels.
Choice D reason: Hypokalemia is a condition of low potassium levels in the blood. It can cause symptoms such as muscle cramps, weakness, fatigue, constipation, and arrhythmias. It is not likely to cause postural hypotension, which is more related to fluid and sodium levels.
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