A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.
You might also like to view...
A patient diagnosed with esophageal reflux disorder has been admitted to the floor. When planning teaching for this patient what should the nurse advise the patient to do?
A) Keep the head of the bed lowered. B) Drink a cup of hot tea before bedtime. C) Avoid carbonated drinks. D) Drink a carbonated drink after meals.
The client with no known metabolic defects has passed a renal calculus and worries about a recurrence. What prevention strategy should the nurse teach this client?
A. "Drink at least 3 to 4 liters of fluid each day." B. "Avoid dairy products and other sources of calcium." C. "Avoid aspirin and aspirin-containing products." D. "Start taking antibiotics at the first sign of a stone."
The family member of a client diagnosed with bipolar disorder asks the nurse what that is. The best response by the nurse would be:
1. "Bipolar disorder means there are cycles of depression as well as hyperactivity, or mania.". 2. "Bipolar disorder is just another type of depression, except depression occurs in cycles.". 3. "Bipolar disorder is a type of depression that includes attention deficit disorder symptoms.". 4. "Bipolar disorder just means that the mood alternates with the seasons, and it becomes worse in the winter.".
A client arrives in the Emergency Department with severe chest pain. What is the best explanation by the nurse to differentiate angina from a myocardial infarction?
1. "Angina usually goes away with rest, and is rarely fatal, but a myocardial infarction requires immediate treatment, and can be life-threatening." 2. "There is no way to tell the difference between the two. You will be treated for a myocardial infarction." 3. "Both are caused by a clot blocking the coronary arteries. Angina occurs if a small vessel is blocked, and a myocardial infarction occurs if a large vessel is blocked." 4. "Angina does not cause severe chest pain, but a myocardial infarction always causes severe chest pain."