A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.

The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.

Choice B is wrong because Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.

The AP did not actually touch the client or carry out the threat, so there was no battery.

Choice C is wrong because Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.

The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.

Choice D is wrong because Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.

The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.

Partial separation of the upper part of the incisional line.

This is a sign of wound dehiscence, which is a serious complication that occurs when the edges of a surgical incision separate and the underlying tissues are exposed.

Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.

Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.

Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.

A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.

Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.

Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.

The nurse should follow these general tips for postoperative abdominal incision care:

• Always wash your hands before and after touching your incisions.
• Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
• Look for any bleeding.

If the incisions start to bleed, apply direct and constant pressure to the incisions.

• Avoid wearing tight clothing that might rub on your incisions.
• Try not to scratch any itchy wounds.
• You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
• After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
• Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks. Do not put any topical ointments or lotions on the incisions.
• Do not rub over the incisions with a washcloth or towel.
• No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.