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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.

Correct Answer is []

Explanation

The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.

Actions to Take:

Use Therapeutic Communication to Build Rapport
Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction.
Teach Coping Skills
Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.

Parameters to Monitor:

Heart Rhythm
Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment.
Vital Signs
Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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