An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?
Evisceration.
Hemorrhage.
Infection.
Dehiscence.
The Correct Answer is A
A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.
Correct Answer is C
Explanation
A. Stating that the healthcare provider left specific instructions may come across as confrontational and does not address the client's emotional state. The focus should be on empathetic communication rather than emphasizing authority.
B. While acknowledging the client’s feelings is important, this response may not de-escalate the situation. It focuses on the necessity of ambulation rather than addressing the client's anger and offering support.
C. Offering to return in 30 minutes provides the client with a sense of control and acknowledges their feelings. It is a supportive and respectful approach that allows time for the client to calm down and prepares them for ambulation.
D. Explaining that ambulation is necessary to avoid complications can sound directive and may not help in managing the client's anger. It is more effective to acknowledge the client's feelings and offer to help at a later time.
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