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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I'll replace the batteries every 2 weeks." - This statement is incorrect. While it's essential to replace hearing aid batteries regularly, the frequency of battery replacement depends on factors such as battery type, usage, and the specific needs of the individual. Providing a specific timeframe like "every 2 weeks" may not be accurate for all clients.
B. "I'll use isopropyl alcohol to clean my hearing aids." - This statement is incorrect. Isopropyl alcohol can damage hearing aids as it may degrade plastic components or affect the adhesives used in their construction. Instead, clients should use a soft, dry cloth or a specialized hearing aid cleaning tool recommended by their audiologist.
C. "I'll clean my ear with cotton swabs before I insert my hearing aids." - This statement is incorrect. Using cotton swabs to clean the ear canal can push earwax deeper into the ear canal, potentially impacting it and interfering with hearing aid function. Clients should avoid inserting anything into their ear canal and consult with their healthcare provider if earwax buildup is a concern.
D. "It will disconnect the battery when I remove my hearing aids." - This statement is correct. Many behind-the-ear (BTE) hearing aids are designed to disconnect the battery when removed from the ear, helping to conserve battery life when not in use. This understanding indicates that the client grasps an essential aspect of caring for their hearing aids.
Correct Answer is B
Explanation
A. Hepatitis A - Hepatitis A vaccine is typically administered in two doses, with the first dose given at 12-23 months of age. It is not routinely given at 2 months of age.
B. Rotavirus - Rotavirus vaccine is recommended for administration at 2 months of age, with subsequent doses given at 4 and 6 months. It helps protect against rotavirus infection, a common cause of severe diarrhea in infants and young children.
C. Influenza - Influenza vaccine is usually not administered until 6 months of age. Infants younger than 6 months are considered too young to receive the influenza vaccine.
D. Varicella - Varicella (chickenpox) vaccine is typically given in two doses, with the first dose recommended at 12-15 months of age. It is not routinely administered at 2 months of age.
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