An emergency department nurse is caring for a patient with a laceration on the lower leg that has become infected. On assessment the nurse realizes that a sign of an inflammatory response con-sists of:
a. wound blanching.
b. coolness at the site of injury.
c. a vascular reaction that delivers fluid, blood, and nutrients to the area.
d. decreased pain sensation.
C
Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to interstitial tissues in an area of injury. This process neutralizes and eliminates pathogens or ne-crotic tissues and establishes a means of repairing body cells and tissues. Signs of inflammation include swelling, redness (not blanching), heat, pain or tenderness, and loss of function in the affected body part.
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A) Sitting upright leaning forward slightly B) Low-Fowler's C) Prone D) Trendelenburg
When the nurse is teaching a woman about the use of a diaphragm, it is important to instruct her that the diaphragm should be rechecked for correct size how often?
1. Every five years routinely 2. When weight gain or loss beyond five pounds has occurred 3. After each birth 4. Only after significant weight loss
The World Health Organization (2002) defines ___________ as an "approach that improves the quality of life of individuals and their families facing life-threatening illness,
through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems." Fill in the blank with correct words.
If you are using a flat bottom sheet, you should
A. tuck the bottom end at least 12 inches under the mattress. B. align the top end even with the top of the mattress. C. tuck the top end 6 inches under the mattress. D. align the bottom end even with the end of the mattress.