A nurse is assisting in caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Position the client in semi-Fowler's position.

Cover the wound with a transparent dressing.

Instruct the client to lie supine with his knees flexed.

Cover the wound with a dry sterile dressing.

Answer and Explanation

The Correct Answer is C

Wound evisceration is a rare but catastrophic surgical emergency characterized by the total separation of all layers of a surgical wound (dehiscence) with the protrusion of internal visceral organs through the incision. It occurs most frequently 3 to 11 days postoperatively and is associated with risk factors that increase intra-abdominal pressure, such as coughing, straining, or vomiting. Evisceration poses an immediate threat to the blood supply of the protruded organs, creating a high risk for tissue ischemia, necrosis, and overwhelming systemic peritonitis. Nursing interventions must focus on minimizing tension on the abdominal wall and protecting the exposed viscera until emergency surgical repair can be performed.

Rationale:

A. Positioning the client in a semi-Fowler's position is an incorrect choice. While a slight elevation of the head can sometimes be used in general respiratory care, a standard semi-Fowler's position can cause the torso to stretch or bend in a way that increases intra-abdominal pressure and allows gravity to force more of the internal organs out through the abdominal wall incision.

B. Covering the wound with a transparent dressing is an incorrect and contraindicated choice. Transparent film dressings do not provide adequate protection or moisture for exposed visceral organs. Eviscerated organs must be kept continuously moist; a transparent film dressing would trap air and cause the exposed bowel to dry out rapidly, leading to tissue friction, ischemia, and necrosis.

C. Instructing the client to lie supine with his knees flexed is the correct action the nurse should take. Placing the client in a low-Fowler's or supine position with the knees bent reduces tension on the abdominal muscles, decreases intra-abdominal pressure, and prevents further protrusion of the internal organs. Alongside this positioning, the immediate nursing priority is to cover the exposed organs with sterile dressings soaked in warm, sterile normal saline to maintain tissue perfusion and moisture, while simultaneously preparing the client for an emergency return to the operating room.

D. Covering the wound with a dry sterile dressing is an incorrect and highly dangerous act. Placing a dry dressing directly onto exposed internal organs causes the visceral tissue to adhere to the gauze fibers. When the dressing is eventually removed or shifted, it will cause severe tissue tearing, capillary damage, and significantly increase the risk of infection and necrosis. All dressings applied to an evisceration must be thoroughly saturated with sterile saline.

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Correct Answer is A

Explanation

Foot care is a critical component of self-management for clients with diabetes mellitus due to the risk of peripheral neuropathy, poor circulation, and delayed wound healing. These factors increase susceptibility to ulcers, infections, and potential limb complications. Proper hygiene, protective footwear, and daily inspection help prevent injury and promote early detection of skin breakdown. Nurses reinforce safe practices that reduce trauma and infection risk.

Rationale:
A. Wearing clean cotton socks daily helps maintain foot hygiene, reduce moisture buildup, and decrease friction that can lead to skin breakdown. Cotton allows better air circulation compared to synthetic materials, lowering the risk of fungal infections and irritation. In clients with conditions such as Type 2 diabetes mellitus, consistent protective foot care is essential to prevent ulcers and complications.

B. Removing ingrown toenails at home is unsafe because it can cause trauma, bleeding, and infection, especially in clients with reduced sensation and poor circulation. Any nail abnormalities should be managed by a healthcare professional or podiatrist. Self-removal increases the risk of serious complications.

C. Using iodine to disinfect foot cuts is not recommended because it can damage healthy tissue and delay wound healing. Modern wound care emphasizes gentle cleansing with mild soap and water or saline solutions. Harsh antiseptics may worsen tissue injury in diabetic wounds.

D. Soaking feet in warm water daily is discouraged because prolonged soaking can macerate the skin and increase the risk of breakdown and infection. Additionally, clients with neuropathy may not accurately sense water temperature, increasing the risk of burns. Short, gentle cleansing is preferred over soaking.

A. Brief Psychiatric Rating Scale B. Mental Status Examination C. Abnormal Involuntary Movement Scale D. Patient Health Questionnaire-9

Correct Answer is C

Explanation

Clients taking long-term antipsychotic medications for conditions such as schizophrenia are at risk of developing extrapyramidal symptoms, including tardive dyskinesia. Tardive dyskinesia is a late-onset movement disorder characterized by repetitive, involuntary movements, often involving the face, tongue, and extremities. Early detection is essential because symptoms may become irreversible if not identified promptly. Nurses use standardized screening tools to monitor for abnormal motor activity in clients receiving antipsychotic therapy.

Rationale:
A. The Brief Psychiatric Rating Scale is used to assess psychiatric symptoms such as depression, anxiety, hallucinations, and overall psychopathology severity. It does not specifically evaluate involuntary motor movements associated with antipsychotic adverse effects. Therefore, it is not appropriate for detecting tardive dyskinesia.

B. The Mental Status Examination evaluates cognitive function, orientation, mood, thought processes, and perception. While it helps assess overall mental functioning in clients with Schizophrenia, it does not specifically screen for extrapyramidal side effects such as tardive dyskinesia.

C. The Abnormal Involuntary Movement Scale is the correct tool because it is specifically designed to detect and measure the severity of involuntary movements associated with long-term antipsychotic use. It assesses facial, oral, and limb movements to identify early signs of tardive dyskinesia, allowing for timely intervention and medication adjustment.

D. The Patient Health Questionnaire-9 is a screening tool used to assess the severity of depressive symptoms. It is not designed to evaluate motor disorders or medication side effects related to antipsychotic therapy. Therefore, it is not appropriate for identifying tardive dyskinesia.

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A nurse is assisting in caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Correct Answer is C

Explanation

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