The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response?
a. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
d. Edema, redness, tenderness, and loss of function
ANS: D
The body's cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.
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