The nurse is preparing to assess a client with tissue damage to the right arm who is also experiencing immunosuppression. After assessing the local reaction, the nurse assesses for a systemic reaction and should expect:
1. the respirations to be slowed.
2. the temperature to be significantly elevated.
3. the heart rate to be slower than normal.
4. a normal temperature.
Answer: 4
1. Respirations will increase with systemic inflammation.
2. The temperature of the client who is immunosuppressed is not likely to be elevated, because the client does not have a normal immune response.
3. The heart rate would be expected to be elevated.
4. The temperature of this client is likely to be normal.
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