The sudden bursting open of the wound's edges is known as:

Dehiscence

Evisceration

Gaping

Distention

Answer and Explanation

The Correct Answer is A

Choice A reason: Dehiscence refers to the separation of layers of a surgical wound, which may be partial or complete.

Choice B reason: Evisceration is a more severe complication where the wound opens and internal organs may protrude.

Choice C reason: Gaping refers to a wound that is open but does not necessarily indicate the layers have separated, as in dehiscence.

Choice D reason: Distention generally refers to swelling or enlargement of an organ or area, not specifically to the opening of a wound.

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Correct Answer is B

Explanation

Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.

Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.

Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.

Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.

A. Auditory hallucinations B. Free-floating anxiety C. Flashbacks D. Delusions of grandeur

Correct Answer is C

Explanation

Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.

Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.

Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.

Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.

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The sudden bursting open of the wound's edges is known as:

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A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?

Correct Answer is B

Explanation

Audrey is a veteran who served in Afghanistan. She finds it very difficult to drive through a parking ramp because she perceives that "There are people hiding behind the pillars! They have guns! Be careful." Audrey is most likely experiencing which of the following?

Correct Answer is C

Explanation

Mr. G is calling out "Nurse!" When you arrive in his room, he tells you to be careful of the snake in the corner. You do not see anything in the corner. Mr. G is experiencing an:

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

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

The term "appendectomy" means:

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

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Lisa is a 22-year-old woman who experiences episodes of extreme muscle rigidity. She sometimes repeats a word or phrase over and over. Attempts to move her are met with increased muscle resistance. What is she exhibiting?