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 C

Explanation

Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

A. Determine the client's level of anxiety. B. Interrupt the compulsive behavior. C. Use negative reinforcement techniques to prevent the client from performing rituals. D. Encourage avoidance of situations that increase anxiety.

Correct Answer is A

Explanation

Choice A reason: Assessing the client's level of anxiety is crucial as it can inform the nurse about the severity of the OCD symptoms and guide further interventions.

Choice B reason: Interrupting compulsive behavior abruptly can cause significant distress to the client and is not recommended without proper behavioral therapy techniques.

Choice C reason: Negative reinforcement techniques are not typically used in OCD management as they can exacerbate anxiety and are not considered therapeutic.

Choice D reason: Encouraging avoidance of anxiety-increasing situations may reinforce OCD behaviors and is not a recommended approach. Exposure and response prevention, a type of cognitive-behavioral therapy, is often used instead.

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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

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Correct Answer is C

Explanation

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

Correct Answer is A

Explanation

A nurse is caring for a client who has positive manifestations of schizophrenia. Which of the following behaviors should the nurse anticipate?

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?

The 3 main types of Phobias as identified by DSM-5 include: (select all that apply)

Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?

During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?