The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?
Fecal impaction
Incisional infection
Health care-associated Clostridium difficile
Paralytic ileus
The Correct Answer is D
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Fear of heights is known as acrophobia, not agoraphobia.
Choice B reason: Fear of blood is known as hemophobia, not agoraphobia.
Choice C reason: Agoraphobia is the fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong, such as shopping in a large mall.
Choice D reason: Fear of speaking is known as glossophobia, not agoraphobia.
Correct Answer is C
Explanation
Choice A reason: Regression involves reverting to an earlier stage of development when faced with stress, which is not what Marie is doing.
Choice B reason: Repression involves unconsciously blocking out painful thoughts or feelings, which is different from Marie's conscious rationalization of her failure.
Choice C reason: Rationalization is a defense mechanism where an individual justifies an unacceptable behavior or feeling with a logical reason, avoiding the true explanation for the behavior. Marie is rationalizing her failure by blaming the instructor rather than accepting her own role in the outcome.
Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not applicable in Marie's case.
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