The nurse recognizes that a patient has an inflammatory response in a surgical wound on the leg when:
a. a foul drainage is coming from the wound.
b. the affected leg is cooler than the other leg.
c. there are raised, red, pruritic welts on the leg.
d. rubor and edema appear around the wound.
D
Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.
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. A nurse is caring for a terminally ill patient who says to the nurse, "If only I could live until my granddaughter has her first birthday." The nurse assesses this patient to be in the stage of grief termed:
A) Disbelief B) Anger C) Acceptance D) Bargaining
The nurse in the clinic is caring for a patient who has seasonal rhinitis and the patient wants to know what causes this to occur. What is the nurse's best response?
A) "You are experiencing symptoms because bacteria have entered the nose and caused an infection." B) "Your upper airways are experiencing an inflammatory response to an inhaled antigen that is causing you to have sneezing and watery eyes." C) "Your sympathetic nervous system is responding to an acute amount of stress in your life causing you to have nasal congestion." D) "Your runny nose and sneezing have occurred because a portion of your lung has collapsed."
Health care facilities have reduced the incidence of serious latex reactions by:
a. Having local and injectable corticosteroids on hand for employees b. Desensitizing staff who are allergic c. Supplying extra handwashing stations in the halls d. Using only powder-free gloves
The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which of the following laboratory values is the best indicator of nutritional status?
1. Creatine phosphokinase (CPK) 2. BUN levels 3. Glycosuria 4. Hemoglobin