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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.
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