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 C
Explanation
Allowing time during the workday when each nurse can demonstrate proficiency is the best way to evaluate staff competency with the new equipment. This method ensures that the nurses can perform the skills correctly and safely under the charge nurse’s supervision and feedback.
Choice A is wrong because verbally questioning the staff about the new equipment does not assess their practical skills or ability to use the equipment correctly.
Choice B is wrong because requiring each nurse to take a written examination about the new equipment does not assess their hands-on skills or ability to troubleshoot problems with the equipment.
Choice D is wrong because asking each nurse to read the procedure and sign a form acknowledging competency does not verify that the nurses have understood the procedure or can apply it in practice.
It also relies on the nurses’ honesty and self-assessment, which may not be accurate or reliable.
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