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 A

Explanation

a. "You feel that your mother does not want you to come back home?" This response uses reflection, a therapeutic communication technique, to encourage the client to express and explore their feelings further.
b. "It's quite common for clients to feel that way after a lengthy hospitalization." While this normalizes the client's feelings, it might dismiss the client's unique emotional experience and does not invite further exploration.
c. "Why don't you talk to your mother? You may find out she doesn't feel that way." This response provides a solution but does not address the client's current emotional state or encourage them to express their feelings.
d. "Your mother seems like an understanding person. I'll help you approach her." This response makes an assumption about the mother and shifts the focus away from the client’s feelings.

A. observation during and after meals. B. adherence to scheduled meal times. C. trips to the local fast food restaurant for foods. D. monitoring during bathroom trips. E. weekly weight checks.

Correct Answer is ["A","B","D"]

Explanation

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic?

Correct Answer is A

Explanation

When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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