A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Gently suction secretions from the wound bed using a 12-gauge sterile catheter.

Cover the area with saline-soaked sterile dressings.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.

Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.

Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.

Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.

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Correct Answer is B

Explanation

Choice A reason: While legs feeling heavy can be a common sensation after a spinal block, it is not as concerning as other potential symptoms.

Choice B reason: Hypotension is a significant concern following a spinal block as it can indicate a high level of blockage affecting the autonomic nerves, which can lead to serious complications.

Choice C reason: Numbness below the injection site is expected after a spinal block and is not typically a cause for concern unless it is prolonged or accompanied by other symptoms.

Choice D reason: Nausea can occur but is less concerning than hypotension, which can have more immediate and severe consequences.

A. Mood and affect B. Memory C. Judgment D. Mood and tone E. Level of awareness and orientation

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Mood and affect are essential components of the mental health status examination, reflecting the patient's emotional state and its expression.

Choice B reason: Memory is a cognitive function that is assessed during the mental health status examination to determine if there are any deficits.

Choice C reason: Judgment is evaluated to understand the patient's decision-making abilities, which can be affected in various mental health conditions.

Choice D reason: "Mood and tone" is not a standard component of the mental health status examination. The term "tone" typically refers to the quality of voice or speech.

Choice E reason: Level of awareness and orientation are assessed to determine the patient's consciousness level and their awareness of time, place, and person.

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A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient receiving a spinal block. Which symptom would most concern the nurse?

Correct Answer is B

Explanation

The mental health status examination includes (select all that apply):

Correct Answer is ["A","B","C","E"]

Explanation

In the Mental Health Status Examination, which of the following focuses on what the person is thinking?

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