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 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.

A. question the client about choices. B. explore problem-solving alternatives. C. express approval or disapproval of the client's thoughts. D. give the client good advice.

Correct Answer is B

Explanation

a. question the client about choices: This might seem confrontational and does not directly help the client with stressors.
b. explore problem-solving alternatives. This is the most therapeutic purpose. Providing feedback helps the client to consider different ways to address and manage their stressors.
c. express approval or disapproval of the client's thoughts: Expressing approval or disapproval is not therapeutic and can inhibit open communication.
d. give the client good advice: Giving advice is not as effective as helping the client develop their own problem-solving skills.

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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

A nurse is caring for a schizophrenic client who is exhibiting delusional thinking, visual hallucinations, suicidal ideations, and periods of depression. The nurse would recognize that the client is displaying which category of schizophrenia?

Correct Answer is B

Explanation

What is the mental health nurse's purpose for providing feedback to a client on a psychiatric unit who is verbalizing concerns about stressors? To:

Correct Answer is B

Explanation

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