A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?
Edema
Petechiae
Urticaria
Crusting over granulated tissue
The Correct Answer is A
The correct answer is: a. Edema.
Choice A: Edema
Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.
Choice B: Petechiae
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.
Choice C: Urticaria
Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.
Choice D: Crusting over granulated tissue
Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.
Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.
Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.
Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.
Correct Answer is A
Explanation
Choice A reason: Decreased energy is a common symptom of OSA due to disrupted sleep patterns and the body's struggle to maintain adequate oxygen levels during apneic episodes. This can lead to excessive daytime sleepiness and fatigue.
Choice B reason: While thyroid disease can be associated with sleep disorders, it is not a direct finding of OSA. However, hypothyroidism can contribute to the development of OSA due to myxedematous changes leading to airway obstruction.
Choice C reason: Pneumonia is not a direct finding of OSA. However, individuals with OSA may be at increased risk for respiratory infections due to repeated episodes of upper airway collapse during sleep, which can lead to aspiration.
Choice D reason: Hypotension is generally not associated with OSA. In fact, OSA is more commonly linked with hypertension due to the sympathetic nervous system activation that occurs with each apneic episode.
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