A client is 48 hours postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Correct Answer: A

Rationale: Gas pains in the periumbilical area postoperatively are often caused by impaired peristalsis and bowel function. Following abdominal surgery, it is common for peristalsis to be reduced due to surgical manipulation and anesthesia effects. This reduction in peristalsis can lead to the accumulation of gas in the intestines, resulting in gas pains. Infection at the surgical site (Choice B) would present with localized signs of infection such as redness, swelling, warmth, and drainage, rather than diffuse gas pains. Fluid overload (Choice C) would manifest with symptoms such as edema, increased blood pressure, and respiratory distress, not gas pains. Inadequate pain management (Choice D) may lead to increased discomfort, but it is not the primary cause of gas pains in the periumbilical area following a small bowel resection.

Correct Answer: A

Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.

Correct Answer: C

Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.

Correct Answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

Correct Answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

Correct Answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

Correct Answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

Correct Answer: A

Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.

Correct Answer: A

Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.