The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?
Blood pressure 110/70
heart rate 86
Hypoactive bowel sounds
Increased restlessness
Negative Homan's sign
Correct Answer : D
a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.
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Related Questions
Correct Answer is A
Explanation
a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.
Correct Answer is D
Explanation
a. Encourage the client to ignore these thoughts and feelings: This invalidates the client's experience and might hinder the therapeutic relationship.
b. Promote safety and immediately terminate the relationship with the client: Termination is a last resort, and transference can be a valuable tool for therapy if addressed constructively.
c. Immediately reassign the client to another staff member: This avoids the issue and doesn't address the underlying cause of transference.
d. Help the client to clarify the meaning of the relationship, based on the present situation. (Correct) Transference is a phenomenon where a client unconsciously redirects emotions and feelings from significant figures in their past onto the nurse. A therapeutic response involves acknowledging these feelings and helping the client explore them in a safe and supportive environment
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