During assessment of a client's infection site, the nurse determines that the site is warm to the touch. How should the nurse explain this warmth to the client?

Question

1. "Infection causes fluid overload in your body, so the infected site gets warm and red."
2. "Your lymphatic system has shut down to keep the infection from spreading, so the site gets warm and red."
3. "The little vessels around your infection are leaking, so the area gets warm and red."
4. "Your body is sending extra blood and white cells to the site to fight the infection."

Answer 1

Correct Answer: 4
Rationale 1: Fluid overload does not cause erythema.
Rationale 2: Blocked lymphatic drainage does not cause erythema.
Rationale 3: Increased capillary permeability does not cause erythema.
Rationale 4: Increased blood flow causes warmth and redness.
Global Rationale: The central purposes of inflammation are to contain the injury, destroy the pathogen, and initiate repair of the area. The repair of the injured area can proceed at a faster pace by neutralizing the foreign agent and removing cellular debris and dead cells. Signs of inflammation include swelling, pain, warmth, and redness of the affected area. Histamine dilates nearby blood vessels, resulting in increased blood flow to the area, sometimes congesting the area with blood. This often results in the area feeling warmer than surrounding tissues.
Fluid overload does not cause this response, nor does blocked lymphatic drainage or decreased capillary permeability.