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
Crusting over granulated tissue
Petechiae
Urticaria
The Correct Answer is A
A. Edema, which is swelling caused by fluid accumulation in the tissues. Edema is a common sign of inflammation and infection in wounds.
B. Crusting over granulated tissue may indicate normal wound healing and is not necessarily a sign of infection.
C. Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They are usually associated with blood disorders or trauma, not infection.
D. Urticaria (hives) is typically associated with allergic reactions and is not a typical sign of wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diazepam can cause side effects, especially drowsiness, even with a single dose.
B. One of the common side effects of diazepam is drowsiness, and the client should be advised not to operate heavy machinery or engage in activities requiring alertness until the effects are known.
C. Avoiding foods that contain tyramine is more relevant for certain antidepressant medications, not diazepam.
D. Grapefruit juice is known to interact with certain medications, but it does not inactivate diazepam.
Correct Answer is A
Explanation
A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.A. Listening to music is a form of distraction, diverting the client's attention away from pain.
B. Biofeedback involves using electronic monitoring to help individuals gain conscious control over physiological processes, not applicable in this context.
C. Guided imagery involves using the imagination to create calming mental images, not directly related to listening to music.
D. Meditation involves a state of focused attention and may not be as directly applicable during a medical procedure.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.
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