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 A
Explanation
The SBAR is used to organize and standardize communication between members of the health care team about a patient’s condition. It is an acronym for Situation, Background, Assessment, and Recommendation.
Choice B is wrong because the SBAR is not used to help Physical Therapy determine the client’s abilities.
Physical Therapy may use other tools or methods to assess the client’s functional status.
Choice C is wrong because the SBAR is not used to help physicians with diagnoses.
The SBAR is a communication tool, not a diagnostic tool.
Physicians may use other sources of information or tests to make diagnoses.
Choice D is wrong because the SBAR is not used to educate clients about their disease processes.
The SBAR is a tool for interprofessional communication, not for patient education.
Clients may receive education from other sources or materials.
Correct Answer is A
Explanation
Urinary catheterization is a common cause of health care-associated infections (HAIs), which are infections that patients get while receiving medical treatment in a health care facility. Urinary catheterization involves inserting a tube into the bladder to drain urine, which can introduce bacteria into the urinary tract and cause infections.
Choice B is wrong because malnutrition is not a direct cause of HAIs, although it can weaken the immune system and increase the risk of infections.
Choice C is wrong because multiple caregivers are not a direct cause of HAIs, although they can increase the exposure to different pathogens and cross contamination if they do not follow proper hygiene and infection control practices.
Choice D is wrong because chlorhexidine washes are not a cause of HAIs, but rather a preventive measure to reduce the risk of HAIs by disinfecting the skin and mucous membranes.
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