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 A

Explanation

Nonmaleficence is the ethical principle of doing no harm or preventing harm to a client. It is based on the Hippocratic oath of “primum non nocere” or “first, do no harm”. It means that the nurse should act in the best interest of the client and avoid any actions that could cause injury or suffering.

Choice B. Fidelity is the ethical principle of being faithful and loyal to a client.

It means that the nurse should keep promises, respect confidentiality, and maintain trust.

Choice C. Justice is the ethical principle of treating clients fairly and equally.

It means that the nurse should distribute resources and services based on the client’s needs and not on personal biases.

Choice D. Autonomy is the ethical principle of respecting a client’s right to make their own decisions.

It means that the nurse should inform the client of their options and support their choices, as long as they do not harm others.

A. The teenager is probably difficult for a single mother to manage, so the family will be referred to social services. B. Further assessment needs to be done to determine if the family needs assistance. C. The mother needs assistance to cope with the stress of raising a teenager on her own. D. The mother will need financial support while she takes off work to care for her son.

Correct Answer is B

Explanation

This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.

Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.

Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.

Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.

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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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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?