An older adult client with no cognitive impairment had a left hip arthroplasty 72 hours ago and is now confused and lethargic. Which action should the nurse implement?

Auscultate for bowel sounds.

Compare pedal pulses bilaterally.

Observe the surgical incision.

Assess mobility of the right leg.

Answer and Explanation

The Correct Answer is B

A. Auscultate for bowel sounds. While monitoring for postoperative ileus is important, it is not the priority intervention in a patient who is suddenly confused and lethargic after hip surgery. Avascular complications, fat embolism, or deep vein thrombosis (DVT) are more immediate concerns.
B. Compare pedal pulses bilaterally. A sudden change in mental status after hip arthroplasty could indicate a fat embolism or deep vein thrombosis (DVT) leading to pulmonary embolism. Comparing bilateral pedal pulses helps assess for signs of vascular impairment or embolic complications, which are serious postoperative risks. Fat embolism syndrome (FES) can cause confusion, lethargy, and respiratory distress, requiring immediate intervention.
C. Observe the surgical incision. While assessing for infection or bleeding is important, these complications do not typically cause sudden confusion and lethargy. Systemic embolic events or impaired circulation are more critical to assess first.
D. Assess mobility of the right leg. Evaluating mobility is part of routine post-arthroplasty care, but it does not directly address the sudden mental status changes seen in this patient. Assessing circulation and embolic risk takes priority.

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Correct Answer is C

Explanation

A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. While peppers and onions provide antioxidants, the presence of processed meat (ham) increases the risk of some cancers, particularly colorectal cancer, due to nitrates and preservatives.
B. Pancakes with blueberries and maple syrup, and a turkey sausage patty. Blueberries are rich in antioxidants, which can help reduce cancer risk, but pancakes with syrup are high in refined carbohydrates and added sugars, which may contribute to inflammation and increased cancer risk.
C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. Oatmeal contains fiber, which helps reduce the risk of colorectal cancer. Raisins and nuts provide antioxidants, while grapefruit is high in vitamin C, which supports immune function and may help protect against some cancers. This is the best balanced meal with cancer-protective nutrients.
D. Poached egg, bacon, biscuit, and canned peaches in light syrup. Bacon is a processed meat linked to an increased risk of colorectal cancer. Biscuits are refined carbohydrates, and canned peaches in syrup contain added sugars, which can contribute to inflammation and chronic disease risk.

A. Anaphylactic. B. Noncompensatory. C. Inflammatory. D. Cholinergic.

Correct Answer is C

Explanation

A. Anaphylactic. Anaphylactic reactions are caused by severe allergic responses, leading to histamine release, vasodilation, and bronchoconstriction. While burns trigger an immune response, it is an inflammatory reaction rather than an allergic one.
B. Noncompensatory. The body's response to burns is compensatory, not noncompensatory. The body immediately reacts by activating the inflammatory and stress responses to maintain perfusion and initiate healing.
C. Inflammatory. A severe burn triggers an immediate and massive inflammatory response, causing capillary leakage, fluid shifts (burn shock), and immune activation. This leads to edema, hypovolemia, and increased risk of infection. The inflammatory response also activates cytokines and white blood cells to begin tissue repair.
D. Cholinergic. The cholinergic response is related to the parasympathetic nervous system, which controls rest-and-digest functions. Severe burns primarily activate the sympathetic nervous system (fight-or-flight), leading to vasoconstriction, tachycardia, and increased metabolic demands.

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An older adult client with no cognitive impairment had a left hip arthroplasty 72 hours ago and is now confused and lethargic. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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