A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Abdominal distention

Watery stool

Dizziness

Oliguria

Answer and Explanation

The Correct Answer is A

A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.

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Correct Answer is B

Explanation

A. Hypertension:
Disulfiram does not typically cause hypertension as an adverse effect. However, consuming alcohol while taking disulfiram can lead to a range of cardiovascular effects, including hypotension rather than hypertension.

B. Headache:
Consuming alcohol while taking disulfiram can result in a severe and rapid onset of symptoms known as the disulfiram-alcohol reaction. Headache is a common symptom of this reaction, along with flushing, nausea, vomiting, and palpitations. Therefore, monitoring for headaches is essential in clients taking disulfiram who report alcohol ingestion.

C. Insomnia:
Insomnia is not a commonly reported adverse effect of disulfiram. The disulfiram-alcohol reaction primarily involves physical symptoms rather than disturbances in sleep patterns.

D. Tinnitus:
Tinnitus, or ringing in the ears, is not a typical adverse effect of disulfiram. However, disulfiram can cause a range of neurological symptoms as part of the disulfiram-alcohol reaction, but tinnitus is not commonly reported.

A. Take antacids that contain mint for heartburn. B. Avoid consuming foods containing chocolate. C. Increase dietary intake of citrus fruits. D. Lie down for 30 min after eating a meal.

Correct Answer is B

Explanation

A. Take antacids that contain mint for heartburn. - This statement is incorrect. While antacids can help neutralize stomach acid and relieve heartburn symptoms, antacids containing mint can relax the lower esophageal sphincter (LES), leading to increased reflux symptoms. Therefore, clients with GERD should avoid antacids containing mint.
B. Avoid consuming foods containing chocolate. - This statement is correct. Chocolate is a common trigger for GERD symptoms due to its high fat content, which can relax the LES and delay stomach emptying, leading to increased acid reflux. Advising the client to avoid foods containing chocolate can help minimize GERD symptoms.
C. Increase dietary intake of citrus fruits. - This statement is incorrect. Citrus fruits are acidic and can exacerbate GERD symptoms by increasing stomach acid production and irritating the esophagus. Therefore, clients with GERD should limit or avoid citrus fruits to reduce acid reflux.
D. Lie down for 30 min after eating a meal. - This statement is incorrect. Lying down after eating can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus more easily. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to help prevent acid reflux.

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A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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