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 D
Explanation
NPH insulin typically peaks in its action approximately 4 to 8 hours after administration. Given that the client received the insulin at 0730, the peak time for signs of hypoglycemia would likely occur between 1100 and 1500.
Correct Answer is B
Explanation
B. After ESWL for a urinary stone, it is essential to monitor the client's urine characteristics (such as color, clarity, and presence of blood) and output. The presence of hematuria is a common and expected finding after ESWL due to the disruption of tissue and blood vessels during the procedure. Monitoring urine output helps assess renal function and ensures adequate hydration, which is crucial for flushing out stone fragments.
A. While monitoring urine specific gravity can provide information about the concentration of urine, and assessing antigen levels may be relevant in certain contexts, these parameters are not typically the most important information to collect immediately after extracorporeal shock-wave lithotripsy (ESWL) for a urinary stone.
C. While it is important to monitor the surgical site for signs of infection or complications after any procedure, ESWL is a non-invasive procedure performed externally, typically without any incisions.
D. While obtaining clean catch urine specimens for urinalysis and culture may be relevant for assessing urinary tract infection or other urinary abnormalities, it is not typically the most important information to collect immediately after ESWL.
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