The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Blood pressure 110/70

heart rate 86

Hypoactive bowel sounds

Increased restlessness

Negative Homan's sign

Answer and Explanation

Correct Answer : D

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

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Correct Answer is C

Explanation

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

A. "I know I can't use physical force anymore, but I can intimidate someone with my words." B. "Because my wife seems to be the one to set me off, I've decided never to see her again." C. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." D. "I realize I have a problem expressing my anger appropriately."

Correct Answer is D

Explanation

a. "I know I can't use physical force anymore, but I can intimidate someone with my words." This indicates that the client still considers using intimidation, which is not a healthy way of managing anger or aggression.
b. "Because my wife seems to be the one to set me off, I've decided never to see her again." Avoiding a trigger rather than managing the response to it does not indicate progress in anger and aggression management.
c. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." Viewing anger as entirely negative and trying to eliminate it rather than managing it constructively does not show effective anger management.
d. "I realize I have a problem expressing my anger appropriately." This is correct because recognizing and admitting the problem is a critical first step toward making meaningful changes in managing anger and aggression.

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The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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