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.

Answer and Explanation

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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Correct Answer is C

Explanation

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

A. “Reporting is voluntary for health care workers.” B. “If suspicion of abuse exists then reporting is mandatory.” C. “Civil liability can result if the abuse can’t be proven.” D. “Evidence of abuse must be collected prior to reporting.”.

Correct Answer is B

Explanation

According to the National Institute on Aging, health care providers play an important role in recognizing and reporting elder abuse. They have a legal and ethical obligation to report any suspected cases of abuse to the appropriate authorities. Reporting is not voluntary for health care workers.

Choice A is wrong because reporting is not voluntary for health care workers. Choice C is wrong because civil liability cannot result if the abuse can’t be proven. Health care providers are protected by immunity laws when they report suspected abuse in good faith.

Choice D is wrong because evidence of abuse does not need to be collected prior to reporting. Health care providers should report any signs or symptoms of abuse, even if they are not conclusive.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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?