A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

Choice A reason: This is the correct answer because paralytic ileus is a condition in which the intestinal motility is decreased or absent, resulting in the inability to pass gas or stool. It is a common complication of abdominal surgery, as the manipulation of the bowel can cause inflammation and nerve damage. The nurse should monitor the client for signs of bowel obstruction, such as abdominal distension, nausea, vomiting, and pain.

Choice B reason: This is not the correct answer because Clostridium difficile colitis is a condition in which the normal flora of the colon is disrupted by antibiotic therapy, allowing the overgrowth of a toxin-producing bacteria that causes inflammation and diarrhea. It is not a common complication of abdominal surgery, but rather a risk associated with prolonged hospitalization and antibiotic use.

Choice C reason: This is not the correct answer because constipation is a condition in which the stool is hard, dry, and difficult to pass. It is not a common complication of abdominal surgery, but rather a side effect of opioid analgesics, which can slow down the bowel movements. The nurse should encourage the client to increase fluid and fiber intake, and use stool softeners as prescribed.

Choice D reason: This is not the correct answer because fecal impaction is a condition in which a large mass of stool is stuck in the rectum, preventing the passage of gas or stool. It is not a common complication of abdominal surgery, but rather a result of chronic constipation, dehydration, or immobility. The nurse should assess the client for signs of impaction, such as abdominal cramping, rectal pressure, and leakage of liquid stool.

Choice A reason: An open wound is a concern for a diabetic client, as it can increase the risk of infection and delay the healing process. However, it does not require an immediate focused assessment, unless it is bleeding profusely, infected, or showing signs of tissue damage.

Choice B reason: Depression is a common complication of diabetes, as it can affect the client's mood, self-care, and adherence to treatment. However, it does not require an immediate focused assessment, unless the client is suicidal, psychotic, or unable to function.

Choice C reason: Chest pain is a symptom that can indicate a life-threatening condition, such as a heart attack, pulmonary embolism, or aortic dissection. It requires an immediate focused assessment, as it can compromise the client's cardiac and respiratory function and lead to death.

Choice D reason: Diabetes is a chronic condition that affects the client's blood glucose levels and can cause various complications, such as neuropathy, nephropathy, and retinopathy. However, it does not require an immediate focused assessment, unless the client is experiencing a hyperglycemic or hypoglycemic crisis.