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?
Watery stool.
Dizziness.
Abdominal distention.
Oliguria.
The Correct Answer is C
Choice A rationale:
Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.
Choice B rationale:
Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.
Choice C rationale:
Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.
Choice D rationale:
Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Epiglottitis can cause airway obstruction, so continuous respiratory monitoring is crucial to detect any signs of respiratory distress.
B. Incorrect. Administering pancreatic enzymes is not relevant to epiglottitis.
C. Incorrect. Frequent swallowing assessment is not the priority for epiglottitis. Airway management is.
D. Incorrect. Suctioning may be necessary, but continuous respiratory monitoring takes precedence.
Correct Answer is ["A","B"]
Explanation
Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg
Heart rate 75min
Respiratory rate 18/min
Explanation:
Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):
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Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
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Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.
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