A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
Answer(s): D
(A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?
Answer(s): B
(A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.
A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this "psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
(A) Guilt relates to depression. (B) Shame is not associated with psychophysiological disorders. (C) Despair relates to depression. (D) Repressed anger is associated with psychophysiological disorders.
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