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

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. Removal (of object), Integrity checks, Condition (treat underlying), Edema relief. B. Rest, Ibuprofen, Circulatory checks, Elevation. C. Redness, Immune response, Cellular regulation, Event. D. Rest, Ice, Compression, Elevation.

Correct Answer is D

Explanation

This is a method of self-care to use right after you experience a minor injury such as a sprain or strain, a minor bone injury, or a sports injury. It quickly treats pain and swelling by reducing inflammation.

Choice A is wrong because Removal (of object), Integrity checks, Condition (treat underlying), Edema relief are not related to RICE and do not form a coherent treatment regimen.

Choice B is wrong because Ibuprofen is not part of RICE and may have side effects such as stomach irritation or bleeding.

Circulatory checks are not necessary unless the compression bandage is too tight.

Choice C is wrong because Redness, Immune response, Cellular regulation, Event are not treatments but symptoms or processes of inflammation.

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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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Correct Answer is C

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Correct Answer is D

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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?