The nurse is assessing two clients who experienced falls the day before and sustained deep tissue damage to their legs. One client's leg is swollen, hot, and red, while the other client's leg shows no sign of damage
The nurse concludes which of the following about the risks of the client with no response to injury? 1. There was no damage from the fall.
2. The bone, not the tissue, was damaged.
3. Healing may be delayed.
4. The client has chronic inflammation.
3. Healing may be delayed.
Rationale:
The client who does not have an inflammatory response to injury may have a chronic disease, such as diabetes, that interferes with phagocytosis due to impaired circulation; consequently, healing may be delayed. The client was seeing the nurse because of an injury to the leg. Bone tissue may have been damaged; in any case, there should be an inflammatory response to injury. Chronic inflammation may be the result of an infectious process that does not heal.
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