Which assessment findings would the nurse evaluate as possibly indicating an inflammatory response?

Question

1. Pain, fever, and tremors
2. Fever, change in level of consciousness, and tremors
3. Pain, irritability, and change in level of consciousness
4. Fever, aches and pains, and lethargy

Answer 1

Correct Answer: 4
Rationale 1: Pain and fever are associated signs and symptoms of the inflammatory process; tremors, however, are not common.
Rationale 2: The inflammatory response causes fever, but not a change in the level of consciousness or tremors.
Rationale 3: The inflammatory response does not cause irritability or a change in the level of consciousness.
Rationale 4: Fever, aches and pains, and lethargy are common signs and symptoms of the inflammatory response.
Global Rationale: Although it is a natural defense mechanism, excessive inflammation causes symptoms that range from minor discomfort to severe, disabling pain, fever, and limitation of mobility. Tremors, change in level of consciousness and irritability are not common finding associated with the inflammatory response.