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":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
A. Wheezes - Latex Allergy. Wheezing is often associated with allergic reactions, including latex allergy. Latex allergy can cause airway constriction and result in wheezing.
B. Tachycardia - All Thr ee Conditions (Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock). Tachycardia can be a common response to stress or physiological changes. In malignant hyperthermia, tachycardia can occur due to the hypermetabolic state. Latex allergy can cause an anaphylactic reaction leading to tachycardia. In hypovolemic shock, the heart rate increases to compensate for decreased blood volume.
C. Urticaria - Latex Allergy. Urticaria (hives) is a classic sign of an allergic reaction, including latex allergy.
D. Hypercapnia - Malignant Hyperthermia. Hypercapnia (elevated levels of carbon dioxide in the blood) can be a sign of malignant hyperthermia due to increased muscle metabolism and metabolic acidosis.
E. Muscle Rigidity - Malignant Hyperthermia. Muscle rigidity is a hallmark sign of malignant hyperthermia, a rare but potentially life-threatening reaction to certain medications used during anesthesia.
Correct Answer is A
Explanation
A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.
B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.
C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.
D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.
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