A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?
3+ palpable pedal pulses below the affected injury site.
Full range of motion at the site of injury.
Sanguineous drainage at the site of injury.
Localized warmth at the site of injury.
The Correct Answer is D
Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.
Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.
Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.
Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.
Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.
The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.
The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.
The nurse should respect the patient’s wishes and help him to exercise his rights and choices.
The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.
Correct Answer is A
Explanation
The correct answer is choice A. Cataracts are a cloudy, opaque area over the lens of one eye that can impair vision
Choice B is wrong because diabetic retinopathy is a condition that affects the blood vessels of the retina, not the lens. It can cause blurred vision, floaters, or vision loss
Choice C is wrong because glaucoma is a condition that damages the optic nerve due to high pressure in the eye. It can cause blind spots, halos around lights, or vision loss
Choice D is wrong because macular degeneration is a condition that damages the macula, the central part of the retina. It can cause blurred or no vision in the center of the visual field
: https://www.nhs.uk/conditions/cataracts/
: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and diseases/diabetic-retinopathy
: https://www.mayoclinic.org/diseases-conditions/glaucoma/symptoms causes/syc-20372839
: https://en.wikipedia.org/wiki/Macular_degeneration
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