The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Fecal impaction

Incisional infection

Health care-associated Clostridium difficile

Paralytic ileus

Answer and Explanation

The Correct Answer is D

Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.

Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.

Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.

Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

A. Develop the patient's plan of care. B. Provide informed consent to the patient. C. Provide emotional support to patients. D. Assist with data collection. E. Include families in preoperative care. F. Reinforce patient teaching.

Correct Answer is ["C","D","E","F"]

Explanation

Choice A reason: LPNs are involved in developing the patient's plan of care by gathering data and collaborating with the RN to ensure the plan is tailored to the patient's needs.

Choice B reason: Providing informed consent is typically the responsibility of the physician or advanced practice nurses, not the LPN.

Choice C reason: LPNs provide emotional support to patients, helping to alleviate anxiety and offering comfort before the surgery.

Choice D reason: LPNs assist with data collection, such as gathering vital signs and medical history, which is crucial for the preoperative assessment.

Choice E reason: Including families in preoperative care is part of the holistic approach to nursing, where LPNs can provide information and support to the patient's family.

Choice F reason: LPNs reinforce patient teaching by reviewing instructions and care plans with the patient and their family to ensure understanding and compliance.

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The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

Which of the following is a role of the LPN in the preoperative phase? Select all that apply.

Correct Answer is ["C","D","E","F"]

Explanation

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The muxtranks are coming. The muxtranks are coming." The nurse correctly recognizes the client's use of the word "muxtranks" as an example of which of the following alterations in speech?

The nurse is collecting admission data on a new patient with a long health history. Which of the following life events is considered a stressor?

The mental health status examination includes (select all that apply):

A nurse is collecting data from a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

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A patient who repeats a word or part of a word over and over might be said to have which of the following symptoms?

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is: