A nurse is caring for a patient who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?
Consumed 35% of meals for 12 hr.
Been on bedrest for 3 days.
Last bowel movement 2 days ago.
Reports pain as 5 on a scale of 0 to 10.
The Correct Answer is D
Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.
Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This statement is not entirely accurate. Crohn’s disease does not resemble a second-degree burn. It is an inflammatory bowel disease that can affect any part of the gastrointestinal tract.
Choice B rationale
While this statement is technically correct, it uses medical jargon that may be difficult for a patient to understand. Crohn’s disease is indeed characterized by transmural granulomatous inflammation, meaning it affects the entire wall of the gastrointestinal tract. However, this description may not be easily understood by a patient without a medical background.
Choice C rationale
This statement is partially correct but not entirely accurate. Crohn’s disease can cause inflammation in the mucosa and sub-mucosa of the colon and rectal linings, but it is not limited to these areas. It can affect any part of the gastrointestinal tract from the mouth to the anus.
Choice D rationale
This is the most simplistic and non-medical description of the disorder. Crohn’s disease can indeed give the appearance of a “patchwork quilt” in the gastrointestinal tract, with some areas
clear and others inflamed or ulcerated. This description provides a visual analogy that may be easier for a patient to understand.
Correct Answer is C
Explanation
Choice A rationale
Hyperthermia and severe tachycardia are not typical symptoms of damage to the parathyroid glands.
Choice B rationale
Hypercalcemia and shortness of breath are not typical symptoms of damage to the parathyroid glands.
Choice C rationale
Laryngospasms and tingling in the hands and feet can be symptoms of hypoparathyroidism, a condition that can occur if the parathyroid glands are damaged. Hypoparathyroidism can lead to low levels of calcium in the blood, which can cause these symptoms.
Choice D rationale
Hypophosphatemia, hypertension, vomiting, and chest pain are not typical symptoms of damage to the parathyroid glands.
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