A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

A. "Since I retired, I have entered many gardening competitions.": Compensation involves emphasizing a strength or engaging in alternative activities to make up for perceived deficiencies or losses. Participating in competitions reflects the client redirecting energy to excel in another area, consistent with this defense mechanism.

B. "I'm so glad I've retired because the work was making me sick and depressed.": This statement reflects relief and rationalization rather than compensation, as the client is explaining the retirement in terms of health and well-being.

C. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Journaling is a coping strategy that promotes reflection and self-esteem, but it is more aligned with intellectualization or sublimation, not compensation.

D. "I had to retire because my boss didn't like me.": This statement demonstrates projection, attributing responsibility for a situation to someone else, rather than compensating for perceived loss or inadequacy.