You are caring for an obese post-operative client who underwent surgery for bowel resection. As the client is moving in bed, he states, 'Something popped open.' Upon examination, you note wound evisceration. Place the following steps in order for handling this complication.

Correct Answer: A

Rationale: In this scenario, the correct step is to choose option A: Stay calm and stay with the client. This is the priority action to ensure the client's emotional support and safety. Remaining calm helps in reassuring the client and prevents further anxiety or panic, which can exacerbate the situation. Option B, putting the client into semi-Fowler's position with knees slightly flexed, is not the immediate priority when dealing with wound evisceration. While positioning is important, the client's emotional and physical stability take precedence. Option C, covering the intestine with sterile moistened gauze, is not recommended as it could lead to complications such as infection or further damage to the exposed tissue. This step should be performed by a healthcare provider with proper training and sterile technique. Option D, having a colleague gather supplies and contact the physician, is also important but should come after ensuring the client's immediate emotional and physical well-being. Contacting the physician should be done promptly but not at the expense of neglecting the client's needs in the moment. Educationally, this scenario highlights the importance of prioritizing actions in emergency situations. Nurses and healthcare providers must be prepared to handle unexpected complications with composure and prioritize client care based on immediate needs. Proper training and knowledge of appropriate steps are crucial in providing safe and effective care in critical situations.

Correct Answer: A

Rationale: Jaundice is a common manifestation of liver disease, including liver cancer, and is characterized by a yellowing of the skin due to an accumulation of bilirubin in the blood. Therefore, option A, "Abnormally high concentration of bilirubin in the blood," is the correct answer. Bilirubin is a yellow pigment formed from the breakdown of red blood cells (RBCs) in the liver. In conditions like liver cancer, the liver's ability to process and excrete bilirubin is impaired, leading to its accumulation in the blood and subsequent yellowing of the skin. Options B, C, and D are incorrect because they do not directly relate to the pathophysiology of jaundice in liver cancer. Option B, "Abnormally low concentration of bilirubin in the blood," is contradictory to the presentation of jaundice. Option C, "Excessive production of RBCs," is not directly linked to the accumulation of bilirubin. Option D, "Excessive production of platelets," is unrelated to the development of jaundice. In an educational context, understanding the mechanism of jaundice in liver disease is crucial for nurses caring for patients with liver cancer. Recognizing the signs and symptoms of jaundice can prompt early intervention and management to address the underlying liver dysfunction. Additionally, a strong foundation in the pathophysiology of liver disease can enhance nurses' ability to provide holistic care and support to patients with gastrointestinal conditions.

Correct Answer: D

Rationale: The correct answer is D) Reflux of gastric contents into the esophagus. As individuals age, changes in the gastrointestinal system occur. One of the common age-related changes is a weakening of the lower esophageal sphincter, which can lead to the reflux of gastric contents into the esophagus, causing symptoms such as heartburn and regurgitation. This is a clinical manifestation that a nurse may find in an older patient. Option A) Gastric hyperacidity is not typically an age-related change in the GI system. While it can occur in individuals of any age, it is not a specific manifestation of aging. Option B) A yellowish tinge to the skin is more indicative of liver dysfunction or issues with the biliary system rather than age-related changes in the GI system. Option C) Intolerance to fatty foods can be seen in various GI conditions such as gallbladder disease or pancreatic insufficiency but is not solely related to age-related changes in the GI system. Educationally, understanding age-related changes in the GI system is crucial for nurses caring for older patients. By recognizing these changes, nurses can provide appropriate care, education, and interventions to help manage symptoms and improve the quality of life for older adults. Regular assessment and understanding of these manifestations can lead to early identification and intervention, improving patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Android body shape and weight gain are influenced by genetics. This statement is accurate because genetics play a significant role in determining body shape and the distribution of fat storage in individuals. Android body shape refers to the distribution of fat predominantly around the abdomen and is often associated with higher health risks compared to gynoid body shape, where fat is mainly distributed around the hips and thighs. Option A is incorrect because obesity is not solely explained by exacerbated changes of aging in older patients. While aging can contribute to changes in metabolism and body composition, genetics also play a crucial role in obesity across all age groups. Option C is incorrect because the incidence of obesity is not solely determined by race. While there may be differences in obesity rates among different racial groups, genetic predisposition, lifestyle factors, and socio-economic factors all play significant roles in obesity prevalence. Option D is incorrect because the ability to lose weight is not solely determined by muscle mass. While it is true that muscle mass can impact metabolism and energy expenditure, weight loss is primarily influenced by a combination of factors including diet, exercise, genetics, and overall lifestyle habits. In an educational context, understanding the role of genetics in obesity is essential for healthcare professionals to provide personalized care and interventions for patients struggling with weight management. By recognizing the genetic component of obesity, healthcare providers can tailor treatment plans to address individual differences in metabolism, fat distribution, and response to various weight loss strategies. This knowledge also highlights the importance of a holistic approach to obesity management that considers genetic, environmental, and behavioral factors.

Correct Answer: C

Rationale: In this scenario, the correct nursing intervention is option C: Do hourly visual checks or use a sitter to keep the patient safe. The rationale behind this choice is that older patients with cardiac or renal insufficiency are at a higher risk for complications from vomiting and antiemetic drug side effects. Therefore, close monitoring for signs of distress, changes in vital signs, or any other adverse reactions is crucial to ensure their safety and well-being. Option A, keeping the patient flat in bed, is not the most appropriate choice because it does not address the need for continuous monitoring and safety measures. Older patients may be more prone to orthostatic hypotension when lying flat for extended periods. Option B, keeping the patient NPO until nausea and vomiting cease, is also not the best choice as it does not directly address the patient's safety concerns. While maintaining NPO status may be necessary in some cases, monitoring the patient for any signs of dehydration or other complications takes precedence. Option D, administering IV fluids rapidly to prevent dehydration, is important in managing fluid balance but may not be the most critical intervention at this point. Monitoring for potential complications and ensuring the patient's safety should come first before initiating fluid replacement therapy. In an educational context, it is essential for nurses to understand the specific considerations when caring for older patients with underlying health conditions. Close monitoring, safety measures, and early intervention are key components of providing quality care to this population, especially when managing gastrointestinal issues and potential side effects of medications. This rationale highlights the importance of patient safety and individualized care in nursing practice.