A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) The client's incision site has eviscerated. Evisceration refers to the protrusion of an organ through a wound or surgical incision. When a post-operative client with a sutured abdominal incision experiences sharp abdominal pain and bowel protrusion, it indicates evisceration, which is a surgical emergency requiring immediate intervention to prevent complications like infection and further tissue damage. Option B) The client's incision site has lacerated is incorrect because laceration refers to a tear in the tissue, while evisceration specifically involves an organ protruding through a wound. Option C) The client's incisional site is approximated is incorrect as it describes the alignment and closure of wound edges, not the protrusion of bowel. Option D) The client's incisional site has dehisced after is also incorrect as dehiscence refers to the separation of wound edges, not organ protrusion. Educationally, understanding the signs and implications of evisceration is crucial for nurses caring for post-operative patients. Prompt recognition and appropriate communication to the physician are vital to ensure timely intervention and prevent further complications in surgical patients. This knowledge is essential for providing safe and effective patient care in clinical settings.

Correct Answer: C

Rationale: In educating a client with fibromyalgia about symptom management, it is crucial to emphasize the importance of establishing a regular sleep pattern, which is the correct option (C). This is because sleep disturbances are common in fibromyalgia and can exacerbate symptoms. By promoting a consistent sleep routine, the nurse can help improve the client's overall well-being and minimize pain and fatigue. Option A, avoiding exercise during flare-ups, is incorrect because regular, gentle exercise is actually beneficial for managing fibromyalgia symptoms. Exercise can help improve flexibility, reduce pain, and enhance overall quality of life for individuals with fibromyalgia. Option B, recommending high-impact exercises like running, is incorrect as these types of exercises can actually worsen symptoms by putting additional strain on the muscles and joints, leading to increased pain and fatigue. Option D, suggesting an increase in calcium and caffeine intake, is also incorrect as there is no strong evidence linking these specific dietary factors to symptom improvement in fibromyalgia. In fact, excessive caffeine intake can disrupt sleep patterns, which is counterproductive for individuals with fibromyalgia. Educationally, this rationale highlights the importance of individualized care in managing fibromyalgia and the significance of evidence-based recommendations in promoting symptom relief and overall well-being for clients with this condition.

Correct Answer: B

Rationale: Inadequate perfusion refers to the insufficient delivery of oxygen and nutrients to tissues due to compromised blood flow. Pallor in toes, as indicated in option B, is a sign of inadequate perfusion. When perfusion is inadequate, there is reduced blood flow to the extremities, leading to a pale or whitish appearance in the toes due to decreased oxygen supply. This is a critical indicator that tissue is not receiving adequate perfusion and may be at risk for damage or necrosis. Intact sensation (option A) does not directly correlate with perfusion status. While intact sensation is important for assessing nerve function, it is not a reliable indicator of perfusion adequacy. Bounding pulses (option C) are actually a sign of increased blood flow and may be present in conditions such as fever or inflammation, not inadequate perfusion. Pink fingers (option D) suggest good circulation and oxygenation, which is contrary to the expected pallor seen in inadequate perfusion. In an educational context, understanding the signs of inadequate perfusion is crucial for healthcare professionals to assess and address circulatory issues promptly. Recognizing these signs can help prevent complications such as tissue damage, organ dysfunction, or even loss of limb. Educating healthcare providers on these indicators enables them to provide timely interventions and improve patient outcomes.

Correct Answer: A

Rationale: In this scenario, the nurse's priority should be option A: Administer antibiotics to the client. The rationale behind this is that osteomyelitis is a serious infection of the bone that requires immediate treatment with antibiotics to prevent further complications such as bone necrosis or systemic infection. Administering antibiotics promptly is crucial in stopping the spread of the infection and promoting the client's recovery. Option B, increasing the client's protein intake, while important for overall healing and immune function, is not the priority in this case. Option C, teaching relaxation breathing to reduce pain, is also beneficial but should come after addressing the infection itself. Option D, providing anti-pyretic therapy to reduce fever, is important but treating the underlying infection with antibiotics takes precedence. Educationally, this question highlights the importance of prioritizing interventions based on the immediate needs of the client. Understanding the urgency of treating infections promptly, especially in conditions like osteomyelitis, is essential for nurses to provide effective and timely care to their patients.

Correct Answer: B

Rationale: The best response by the nurse is option B) "Protein has amino acids that promote wound healing." This response is correct because proteins contain essential amino acids that are crucial for tissue repair and regeneration, which are essential for healing bedsores. Proteins play a vital role in the body's healing process by aiding in the formation of new tissue and supporting the immune system. Option A) "Because it is easy to digest" is incorrect as the ease of digestion is not the primary reason for providing protein supplements in this context. The main purpose is to supply the body with essential building blocks for tissue repair. Option C) "If you do not like it, you do not have to take it" is incorrect as it dismisses the importance of the protein supplements for wound healing. It is essential for the nurse to educate the client on the rationale behind the prescribed treatment. Option D) "These supplements have nothing to do with your wound" is incorrect as protein supplements do play a significant role in supporting wound healing by providing the necessary nutrients for tissue repair. In an educational context, it is crucial for healthcare providers to understand the rationale behind specific treatments and interventions to provide holistic care to patients. By explaining the role of protein in wound healing to the client, the nurse can empower them to actively participate in their healing process and make informed decisions about their care.