A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?
Client report of back pain of 7 on a 0 to 10 scale
Excoriated folds of the client's panniculus
Hypoactive bowel sounds upon auscultation
urine output of 80 mL in the past hour
The Correct Answer is A
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
Correct Answer is D
Explanation
Choice A rationale:
Increasing fiber intake is a key recommendation for managing diverticulosis.
Choice B rationale:
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
Choice C rationale:
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
Choice D rationale:
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
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