A nurse is caring for a client diagnosed with a paralytic ileus. What would be an expected assessment finding?
Pencil-thin stools
Fecal-smelling breath
Passage of mucus and blood in stools
Absent bowel sounds and absent passage of flatus
The Correct Answer is D
D. In paralytic ileus, there is a lack of bowel motility, resulting in absent or diminished bowel sounds on auscultation and absent passage of flatus. The bowel sounds may be hypoactive or completely absent due to the lack of peristalsis. Additionally, the client may experience abdominal distention and discomfort due to the accumulation of gas and fluid in the intestines.
A. Pencil-thin stools are more commonly associated with conditions such as colorectal cancer or rectal strictures. In paralytic ileus, where there is a lack of bowel motility, the stools are typically absent rather than thin.
B. Fecal-smelling breath is not a typical finding in paralytic ileus. While it may occur in conditions associated with severe constipation or bowel obstruction, it is not specific to paralytic ileus.
C. Passage of mucus and blood in stools is not a characteristic finding of paralytic ileus. It is more commonly associated with conditions such as inflammatory bowel disease or colorectal cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Bariatric surgery, such as gastric bypass or sleeve gastrectomy, is considered the most effective intervention for sustained weight loss in the extremely obese population. Bariatric surgery leads to significant weight loss and improvement in obesity-related comorbidities such as type 2 diabetes, hypertension, and obstructive sleep apnea.
A. Medications may help in conjunction with lifestyle modifications such as diet and exercise, but they are not typically the primary intervention for sustained weight loss in extremely obese individuals.
C. While dietary modifications are essential for weight loss and management, traditional dieting alone may not provide the most sustained weight loss in the extremely obese population.
D. Regular physical activity is important for overall health and can contribute to weight loss and weight maintenance. However, an exercise program alone may not provide the most sustained weight loss in the extremely obese population, especially without accompanying dietary modifications.
Correct Answer is A
Explanation
A. Teach the client to support the surgical site while deep breathing and coughing: This action is appropriate as it helps prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. Supporting the surgical site while deep breathing and coughing helps reduce pain and discomfort during these activities.
B. This is an important teaching point for clients using PCA for pain control after surgery. Opioid medications used in PCA can lead to gastrointestinal motility issues, including constipation. However, pain management is central within the first 24 hours post operation.
C. Irrigating and repositioning the NGT frequently can increase the risk of complications such as displacement or irritation of the surgical site. NGT care should be performed as needed based on institutional protocols and the client's condition.
D. The client's diet will likely be advanced gradually, starting with clear fluids and progressing to full liquids and then solid foods as tolerated. Fruit juices may be introduced gradually as part of the liquid diet once the client's gastrointestinal function has recovered sufficiently.
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