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?
Watery stool.
Dizziness.
Abdominal distention.
Oliguria.
The Correct Answer is C
Choice A rationale:
Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.
Choice B rationale:
Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.
Choice C rationale:
Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.
Choice D rationale:
Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
The nurse should discuss the following dietary recommendations with the client who has Crohn's disease:
Avoid eating fried, fatty foods and large meals: Fried and fatty foods can be difficult to digest and may worsen symptoms of diarrhea and abdominal pain. Consuming large meals can also put additional strain on the digestive system.
Limit high fiber foods, such as beans, popcorn, and seeds: High fiber foods can be challenging to digest and may exacerbate symptoms of Crohn's disease. Limiting these foods can help reduce gastrointestinal irritation and promote symptom relief.
Take a vitamin supplement daily with a meal: Crohn's disease can lead to nutrient deficiencies due to malabsorption. Taking a daily vitamin supplement with a meal can help ensure that the client receives essential nutrients and maintain overall nutritional status.
The following options are not appropriate dietary recommendations for a client with Crohn's disease:
- Drinking dairy and effervescent sodas for hydration: Dairy products can trigger symptoms in some individuals with Crohn's disease, especially if they have lactose intolerance. Effervescent sodas may contain carbonation and artificial sweeteners that can aggravate symptoms. Encouraging non-dairy sources of hydration, such as water or herbal teas, would be more appropriate.
- Enjoying fast food restaurants only if dining with friends: Fast food options are generally high in fat, sodium, and other additives that may worsen symptoms in individuals with Crohn's disease. It is advisable to limit or avoid fast food consumption altogether, regardless of whether dining alone or with others.
Correct Answer is A
Explanation
A. Correct. At 12 weeks of gestation, the nurse should position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
B. Fundal height measurement is used to assess uterine growth and is not applicable for assessing fetal heart rate.
C. Placing the client in a side-lying position is not necessary for assessing fetal heart rate at 12 weeks of gestation.
D. Leopold maneuvers are used to determine fetal position and lie and are not directly related to auscultating the fetal heart rate.
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