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.
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Related Questions
Correct Answer is A
Explanation
This means that the blood flow to the affected area is reduced due to narrowed or blocked arteries. This can cause tissue death or gangrene. Diabetes can
damage the blood vessels and affect blood flow, increasing the risk of gangrene. Choice B. Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.
Choice C. Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.
Choice D. Varicose veins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.
Correct Answer is ["B","C","D"]
Explanation
These are signs of anemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
Anemia can cause fatigue, weakness, pale skin, cold hands and feet, dizziness, reduced immunity and shortness of breath.
Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.
Choice E is wrong because flushed skin is not a sign of anemia. Anemia can cause pallor, which is pale or yellowish skin.
Flushed skin can be a sign of other conditions, such as fever, infection or allergic reaction.
Normal ranges for hemoglobin levels vary depending on age and gender. For adult males, the normal range is 13.5 to 17.5 grams per deciliter (g/dL) of blood. For adult females, the normal range is 12 to 15.5 g/dL of blood.
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