The nurse would be concerned that a patient is exhibiting signs and symptoms of inflammation after assessing which findings in a leg wound? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Edema
2. Pain
3. Erythema
4. Coolness of tissues
5. Decreased distal pulses
1,2,3
Rationale 1: Edema results from vasodilation and leaking of fluid into the surrounding tissues.
Rationale 2: Pain results from swelling and prostaglandin release.
Rationale 3: Erythema is related to vasodilation and is a cardinal sign of inflammation.
Rationale 4: Warmth at the site is a sign of inflammation.
Rationale 5: Decreased distal pulses are not a typical sign of inflammation.
You might also like to view...
The prepayment plan developed in 1929 is
a. Blue Cross Health Insurance. b. Medicare Insurance. c. Medicaid Insurance. d. Health Maintenance Organization.
Which term would you use to document a respiratory rate more than 20 breaths/min in an adult?
a. Dyspnea b. Orthopnea c. Platypnea d. Tachypnea
A client is beginning therapy with auranofin (Ridaura), so the nurse realizes the client will need teaching about:
a. an injectable gold product. c. a nonsteroidal anti-inflammatory agent. b. an oral gold product. d. a corticosteroid.
A novice nurse says, "We want to keep our patients in Stage 4 anesthesia during their surgery." How should the supervising nurse interpret this statement?
1. The novice nurse has made an error in this statement. 2. Stage 4 anesthesia is avoided. 3. This is a good description of the goal of anesthesia. 4. The novice nurse should have said Stage 3 anesthesia. 5. A more accurate statement would be that the patient is maintained in anxiolysis anesthesia.