A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

The correct answer is: a. Temperature, c. Color, d. Sensation.

Choice A: Temperature

Reason: Monitoring the temperature of the affected extremity is crucial in evaluating neurovascular status. A cool or cold extremity can indicate decreased perfusion, which may be a sign of neurovascular compromise. Normal skin temperature should be warm to the touch, indicating adequate blood flow.

Choice B: Ecchymosis

Reason: Ecchymosis, or bruising, is not a direct indicator of neurovascular status. While it can provide information about trauma or bleeding, it does not assess the functionality of nerves or blood vessels in the affected extremity.

Choice C: Color

Reason: Assessing the color of the extremity is essential. Pallor or cyanosis can indicate poor blood flow or oxygenation, which are critical signs of neurovascular impairment. Normal color should be consistent with the rest of the body, indicating good circulation.

Choice D: Sensation

Reason: Evaluating sensation helps determine if there is any nerve damage or impairment. Changes in sensation, such as numbness or tingling, can indicate neurovascular compromise. Normal sensation should be intact and symmetrical with the unaffected extremity.

Choice E: Skin Integrity

Reason: While skin integrity is important for overall wound healing and infection prevention, it is not a primary parameter for assessing neurovascular status. It does not provide direct information about blood flow or nerve function.

Choice A reason:
Abdominal distention can be a sign of delayed return of peristalsis or ileus, especially when accompanied by other symptoms such as nausea, vomiting, or lack of bowel movement. It is not typically a sign that peristalsis is returning.

Choice B reason:
A request for a cup of tea and some toast may indicate that the client is feeling better and is hungry, which can be a good sign. However, it is not a definitive clinical indicator of the return of peristalsis. The desire to eat does not necessarily mean that the digestive system is ready to process food.

Choice C reason:
Hypoactive bowel sounds in two quadrants may indicate that peristalsis is present but weak. While this could be a sign that peristalsis is starting to return, it is not as strong an indicator as the passage of flatus or stool.

Choice D reason:
The passage of flatus is a clear sign that peristalsis is returning. It indicates that gas is moving through the intestines, which is a function of peristalsis. This is often one of the first signs that the gastrointestinal system is recovering after surgery.