A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

Ambulate the client 48 hr after the procedure.

Provide a soft diet on the first postoperative day.

Provide 60 mL (2 oz) of fluid intake every 5 min.

Measure and compare abdominal girth daily.

Answer and Explanation

The Correct Answer is D

A) Ambulate the client 48 hr after the procedure: Early ambulation is important to prevent complications such as deep vein thrombosis and promote recovery. However, ambulating the client 48 hours after the procedure may be too late. Early mobilization, usually within the first 24 hours, is encouraged.

B) Provide a soft diet on the first postoperative day: After gastric bypass surgery, the client typically starts with clear liquids and gradually progresses to a soft diet. Providing a soft diet on the first postoperative day is not appropriate and could cause complications.

C) Provide 60 mL (2 oz) of fluid intake every 5 min: Fluid intake should be carefully monitored and gradually increased. Providing 60 mL of fluid every 5 minutes is excessive and could lead to discomfort or complications such as dumping syndrome.

D) Measure and compare abdominal girth daily: Measuring and comparing abdominal girth daily helps monitor for signs of complications such as internal bleeding or anastomotic leaks. This intervention is crucial for early detection and prompt management of potential issues

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Correct Answer is C

Explanation

A) A lack of empathy is more commonly associated with antisocial personality disorder rather than obsessive-compulsive personality disorder (OCPD). Individuals with OCPD may have difficulty expressing emotions, but they often maintain a sense of morality and are capable of empathy, albeit it may be less visible due to their rigid thinking.

B) Lability, or rapid mood changes, is typically seen in borderline personality disorder rather than OCPD. Clients with obsessive-compulsive personality disorder often exhibit a stable mood but may be seen as overly serious or focused on order and control.

C) Clients with obsessive-compulsive personality disorder tend to be goal-oriented. They often exhibit perfectionism, meticulousness, and a strong need for orderliness, which drives their behavior. This focus on goals and tasks is a hallmark of OCPD, distinguishing it from other personality disorders that may not have this same level of achievement orientation.

D) Provocative behavior is more indicative of borderline or histrionic personality disorders. Individuals with OCPD typically do not engage in attention-seeking or provocative behaviors; instead, they are more reserved and focused on their own rigid standards and tasks.

A. Occupational therapist B. Physical therapist C. Speech-language pathologist D. Dietitian

Correct Answer is C

Explanation

A) An occupational therapist focuses on helping clients regain independence in daily activities and may assist with adaptive techniques for self-care. However, for a client with dysphagia, their primary need is related to swallowing, not daily tasks.

B) A physical therapist specializes in mobility and physical function. While they play an important role in overall physical health, they are not the primary resource for addressing dysphagia, which involves the swallowing process.

C) Consulting a speech-language pathologist is the priority. This professional specializes in communication and swallowing disorders. They can assess the severity of the dysphagia and recommend safe swallowing techniques or interventions to reduce the risk of aspiration, making them essential in the management of a client with amyotrophic lateral sclerosis.

D) A dietitian can provide guidance on nutrition and diet modifications to accommodate dysphagia. While important, the immediate priority is to address the swallowing difficulties through evaluation and intervention by a speech-language pathologist.

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A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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