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A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Exhibits

Complete the following sentence by using the lists of options.

The child is at risk for developing

as evidenced by their. and.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

  • Postoperative ileus: Ileus is a common complication after abdominal surgery due to anesthesia, opioid use, and limited mobility. It presents as delayed return of bowel function, marked by absent bowel sounds and abdominal discomfort. In this case, the child has absent bowel sounds and increasing tenderness, supporting this risk.
  • Atelectasis: Atelectasis generally presents with diminished breath sounds and hypoxia, not clear breath sounds. Although the child has shallow respirations and is refusing the incentive spirometer, there are no respiratory findings such as decreased oxygen saturation or adventitious breath sounds that support this condition currently.
  • Peritonitis: Peritonitis would present with systemic symptoms like fever, severe abdominal pain, rebound tenderness, or signs of sepsis. The child has mild abdominal tenderness and stable vital signs, which do not indicate peritoneal inflammation at this time.
  • Urinary retention: This would be characterized by lack of urination, bladder distension, or discomfort—none of which are noted in the scenario. The child’s urinary output and bladder status are not identified as concerns, making this diagnosis unlikely.
  • Absent bowel sounds:  This is a key clinical sign of ileus. After surgery, bowel activity should return gradually. Continued absence of sounds, especially along with abdominal tenderness, strongly indicates impaired gastrointestinal motility.
  • Shallow respirations: While shallow breathing is often a contributing factor to respiratory complications, in the context of abdominal surgery, it also limits diaphragmatic movement, which can further suppress bowel activity and contribute to postoperative ileus.
  • Clear breath sounds:  This is a normal respiratory finding and does not support the presence of atelectasis or other pulmonary complications. It suggests that lung fields are adequately ventilated despite shallow breathing.
  • Intact abdominal dressing: This is an expected postoperative finding and does not support a diagnosis of infection, wound complication, or ileus. It indicates proper surgical wound healing.


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Related Questions

Correct Answer is C

Explanation

A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.

Correct Answer is B

Explanation

A. Delayed. Delayed grief is characterized by the postponement or suppression of grieving responses, often surfacing long after the loss has occurred. It does not apply here, as the family member is expressing active emotional struggle before the loss.
B. Anticipatory. Anticipatory grief occurs before an actual loss, such as when a loved one is dying from a terminal illness. The family member is beginning to grieve the impending death and the emotional impact of the future loss, which fits this type of grief.
C. Disenfranchised. Disenfranchised grief refers to grief that is not openly acknowledged or socially supported, such as the death of an ex-partner or a pet. In this scenario, the grief is acknowledged and supported, so this does not apply.
D. Exaggerated. Exaggerated grief involves intense symptoms that interfere with daily functioning, such as severe depression, phobias, or suicidal thoughts. The family member is expressing difficulty, but not at a level that indicates dysfunction.

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