The nurse is assessing a client with inflammation of the right knee. In order to determine whether the inflammation has becomes systemic, the nurse should assess:
1. the eyes for jaundice.
2. the lymph nodes in the groin.
3. the client's level of pain.
4. swelling in the arms.
Answer: 2
1. Jaundice in the eyes is an indication of liver failure.
2. If the lymph nodes, particularly in the groin, are swollen, the nurse should be concerned that the inflammation has become systemic.
3. The client's level of pain does not indicate local or systemic inflammation.
4. Swelling in the arms is a local response to inflammation and would not be associated with the inflammation of the knee.
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