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

Instruct the client to lie supine with his knees flexed.

Position the client in semi-Fowler's position.

Cover the wound with a dry sterile dressing.

Cover the wound with a transparent dressing.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

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Correct Answer is D

Explanation

The correct answer is D.

Chadwick's sign. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva caused by increased blood flow to these areas during pregnancy. It usually appears around 6 to 8 weeks of gestation and persists until delivery. It is one of the presumptive signs of pregnancy, which are subjective changes that suggest pregnancy but are not conclusive. Ballottement is a technique of palpating the uterus to detect fetal movement when a finger is inserted into the vagina and tapped against the cervix. It can be performed between 16 and 28 weeks of gestation and is also a presumptive sign of pregnancy.

Chloasma is a condition characterized by brown patches on the face that may occur during pregnancy due to hormonal changes. It is also known as melasma or mask of pregnancy and usually fades after delivery. Hegar's sign is a softening of the lower uterine segment that can be felt during bimanual examination around 6 weeks of gestation. It is one of the probable signs of pregnancy, which are objective changes that strongly indicate pregnancy but are not diagnostic.

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

Correct Answer is D

Explanation

Answer: D. Abnormal Involuntary Movement Scale

Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.

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A nurse is 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

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