The sign or symptom that suggests that a patient with impaired skin integrity is developing a systemic infection is:
1. a lesion on the patient's leg that is swollen and warm to the touch.
2. a temperature that has risen to 101ยบ F.
3. blood pressure that has risen from 126/84 to 130/86.
4. a request by the patient for medication for severe itching.
2
Rise in temperature is a systemic response. Normal blood pressure, warmth, swelling, and itching are not evidence.
PTS: 1 DIF: Cognitive Level: Application
REF: 1138, Nursing Care Plan OBJ: 2
TOP: Systemic Infection KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
You might also like to view...
A nurse is caring for a client with an implanted catheter. The nurse knows that a dressing is applied over the implanted catheter on which of the following occasions?
A) When the client requires extended therapy B) When the effect of the local anesthetic is reduced C) When the client has an active infection D) When the port is pierced and a catheter is in use
Which patient is likely to receive Rho(D) immune globulin (RhIG)?
1. A pregnant woman who is Rho negative 2. A renal transplant patient who is Rho positive 3. A bone marrow transplant patient who is Rho negative 4. A heart transplant patient who is Rho positive
Members of some cultures consider making eye contact a sign of disrespect
Indicate whether the statement is true or false
Pooling of blood in the veins that is associated with immobility, obesity, pregnancy, CHF, and steroid therapy can lead to
A. shock. B. hypertension. C. thrombophlebitis. D. ventricular fibrillation.