A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him in bed. What force caused the injury?

Choice A reason: Fistula is a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin. Fistula can occur as a result of infection, inflammation, trauma, surgery, or congenital defect. Fistula can cause pain, bleeding, discharge, or leakage of fluids or gases from the affected organs or tissues. Fistula can also increase the risk of infection, obstruction, or perforation of the involved organs or tissues.

Choice B reason: Hemorrhage is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an excessive or uncontrolled bleeding from the wound site. Hemorrhage can occur as a result of trauma, surgery, infection, or coagulation disorder. Hemorrhage can cause pain, swelling, bruising, or shock at the wound site. Hemorrhage can also lead to blood loss, anemia, or hypovolemia.

Choice C reason: Infection is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an invasion and multiplication of microorganisms in the wound site. Infection can occur as a result of contamination, poor hygiene, or impaired immunity. Infection can cause pain, redness, warmth, swelling, or pus at the wound site. Infection can also trigger inflammation, fever, or systemic illness.

Choice D reason: Evisceration is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is a protrusion of internal organs or tissues through the wound site. Evisceration can occur as a result of dehiscence, which is a separation or splitting open of the wound edges. Evisceration can cause pain, bleeding, or shock at the wound site. Evisceration can also expose the internal organs or tissues to injury, infection, or necrosis.

Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.

Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.

Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.

Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.