A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Abdominal distention

Watery stool

Dizziness

Oliguria

Answer and Explanation

The Correct Answer is A

A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.

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Correct Answer is A

Explanation

A. A child who has acute epiglottitis and is drooling: Acute epiglottitis is a medical emergency that can rapidly progress to airway obstruction and respiratory distress. Drooling is a significant sign of airway compromise in children with epiglottitis due to swelling of the epiglottis. This child requires immediate assessment and intervention to ensure airway patency.
B. A child who has mononucleosis and reports severe fatigue: While mononucleosis can cause severe fatigue, it is not an immediate life-threatening condition compared to acute epiglottitis. Assessment and intervention for severe fatigue can be prioritized after addressing the child with potential airway compromise.
C. A child who has Wilms' tumor and an abdominal mass: Wilms' tumor is a type of kidney cancer that typically presents with an abdominal mass. While it requires timely medical intervention, it is not as urgent as acute epiglottitis, which poses a risk of airway obstruction.
D. A child who has a urinary tract infection and bright red blood in their urine: While a urinary tract infection with hematuria requires assessment and treatment, it is not immediately life-threatening compared to acute epiglottitis. Addressing the child with potential airway compromise takes precedence over evaluating and managing hematuria.

A. Human papillomavirus (HPV) B. Rotavirus C. Herpes zoster D. Diphtheria, tetanus, and acellular pertussis (DTaP)

Correct Answer is C

Explanation

A. Human papillomavirus (HPV): HPV vaccination is typically recommended for adolescents and young adults to prevent HPV infection, which can lead to cervical cancer and other related diseases. It is not typically indicated for older adults.
B. Rotavirus: Rotavirus vaccination is recommended for infants to protect against severe diarrhea caused by rotavirus infection. It is not indicated for older adults.
C. Herpes zoster: Herpes zoster vaccination, also known as the shingles vaccine, is recommended for older adults to prevent shingles, a painful rash caused by the reactivation of the varicella-zoster virus. The risk of developing shingles increases with age, and vaccination can reduce the risk and severity of the condition.
D. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP vaccination is typically administered to children to protect against diphtheria, tetanus, and pertussis (whooping cough). Tdap is the vaccine formulation recommended for adults, which includes tetanus, diphtheria, and pertussis components.

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A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

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