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. Thorough explanations with details: This approach may overwhelm a client with a cognitive disorder due to complexity and length.
b. Stimulating words and phrases: Stimulating words and phrases can be confusing and may not be understood clearly by a client with cognitive impairment.
c. Short words and simple sentences: This is correct because it ensures clarity and facilitates understanding, which is essential when communicating with someone who has a cognitive disorder.
d. Pictures or gestures instead of words: While visual aids can be helpful, they should complement, not replace, verbal communication unless the client has severe communication difficulties.

A. Psychotic disorder B. Schizoaffective disorder C. Paranoid disorder D. Schizophreniform disorder

Correct Answer is B

Explanation

a. Psychotic disorder: Schizophrenia is a well-defined psychotic disorder characterized by delusions, hallucinations, and disorganized thinking, but it doesn't specifically address the mood component present in this case.
b. Schizoaffective disorder: Schizoaffective disorder is characterized by symptoms of both schizophrenia (such as delusions and hallucinations) and mood disorders (such as depression or mania). The presence of delusional thinking and visual hallucinations, combined with periods of depression and suicidal ideations, fits the profile of schizoaffective disorder.
c. Paranoid disorder: Paranoid disorder is characterized by a pervasive pattern of suspicion and distrust, but it doesn't necessarily involve hallucinations or disorganized thinking like schizophrenia.
d. Schizophreniform disorder: Schizophreniform disorder is similar to schizophrenia but with a shorter duration of symptoms (less than 6 months). The prompt doesn't specify the duration, making schizophrenia a more likely diagnosis.

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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

Which of the following will the nurse use when communicating with a client who has a cognitive disorder?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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