The nurse is bathing a patient and notices movement in the ...

[stephzh]

The nurse is bathing a patient and notices movement in the patient's hair. The nurse should
 
  a. Ignore the movement and continue.
  b. Use gloves or a tongue blade to inspect the hair.
  c. Examine the hair without gloves to make picking lice easier.
  d. Shave the hair off of the patient's head.

Question 2

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
 
  a. Complaint by patient that something has given way
  b. Protrusion of visceral organs through a wound opening
  c. Chronic drainage of fluid through the incision site
  d. Drainage that is odorous and purulent

[olderstudent]

Answer to Question 1

B
In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. Suspicions cannot be ignored. If pediculosis capitis (head lice) is suspected, the nurse must protect himself/herself against self-infestations by handwashing and by using gloves or tongue blades to inspect the patient's hair. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice.

Answer to Question 2

A
occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.