The nurse assesses the wound of a client who received sutures for a laceration of the hand two days ago. Which finding is a normal inflammatory response?
Shivering.
Purulent drainage.
Temperature of 102° F (37.8° C).
Redness and localized heat.
The Correct Answer is D
A) Shivering:
Shivering is not a normal inflammatory response to wound healing. It may indicate systemic symptoms such as fever or chills, which could be indicative of infection or other complications.
B) Purulent drainage:
Purulent drainage (pus) is often a sign of infection rather than a normal inflammatory response to wound healing. While some serous or serosanguinous drainage may be expected initially, purulent drainage suggests an abnormal response.
C) Temperature of 102° F (37.8° C):
A temperature of 102° F (37.8° C) is indicative of fever, which can occur in response to infection or inflammation. While fever is part of the inflammatory response, it is not necessarily considered a normal finding in the context of wound healing and may indicate an abnormal response such as infection.
D) Redness and localized heat:
Correct. Redness (erythema) and localized heat are typical signs of the inflammatory phase of wound healing. Inflammation is a normal response to tissue injury and is characterized by increased blood flow to the area, resulting in redness and warmth. These signs indicate that the body's immune response is active and working to repair the injured tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gastric carcinoma:
Helicobacter pylori infection is a known risk factor for the development of gastric carcinoma, or stomach cancer. Long-term follow-up is essential for clients treated for gastric ulcers caused by H. pylori infection to monitor for any signs or symptoms of gastric malignancy, such as persistent abdominal pain, unexplained weight loss, dysphagia, or gastrointestinal bleeding. Regular surveillance with endoscopic examinations may be recommended to detect any precancerous or cancerous changes in the gastric mucosa.
B. Hypokalemia:
Hypokalemia, or low potassium levels, is not directly associated with gastric ulcers caused by H. pylori infection. While certain medications used in the treatment of gastric ulcers, such as proton pump inhibitors (PPIs) or H2-receptor antagonists, may increase the risk of hypokalemia, it is not a long-term complication specifically related to H. pylori infection.
C. Kidney stones:
Kidney stones, or nephrolithiasis, are not directly associated with gastric ulcers caused by H. pylori infection. Kidney stones typically form in the kidneys and urinary tract due to factors such as dehydration, dietary factors, or metabolic disorders. While certain conditions, such as chronic kidney disease, may be associated with gastric ulcers, kidney stones are not a typical long-term complication.
D. Celiac disease:
Celiac disease is an autoimmune disorder characterized by an abnormal immune response to gluten, a protein found in wheat, barley, and rye. It is not directly associated with gastric ulcers caused by H. pylori infection. Celiac disease primarily affects the small intestine, leading to inflammation and damage to the intestinal lining in response to gluten ingestion. While individuals with celiac disease may experience gastrointestinal symptoms, they are not at increased risk for gastric ulcers specifically related to H. pylori infection.
Correct Answer is D
Explanation
A) Bronchioles:
Bronchioles are small airways in the lungs that lack cartilage and are primarily responsible for conducting air to the alveoli. While changes in bronchioles, such as bronchoconstriction or bronchiolitis, can contribute to airflow limitation in conditions like asthma or chronic bronchitis, they are not primarily associated with the pathophysiological processes of emphysema.
B) Trachea:
The trachea, or windpipe, is the large airway that connects the larynx to the bronchi. It serves as a conduit for air movement into and out of the lungs but is not directly involved in gas exchange. Changes in the trachea are not typically associated with the pathophysiological processes of emphysema.
C) Bronchi:
Bronchi are larger airways in the lungs that branch off from the trachea and further divide into bronchioles. While chronic bronchitis, a common comorbidity of emphysema in chronic obstructive pulmonary disease (COPD), primarily affects the bronchi, it is not the primary structure associated with the pathophysiological processes of emphysema.
D) Alveoli:
Correct. Emphysema is a type of COPD characterized by the destruction of alveolar walls, leading to enlarged airspaces and loss of lung elasticity. This structural damage results in decreased surface area for gas exchange and impaired diffusion of oxygen and carbon dioxide across the alveolar-capillary membrane. Alveolar destruction in emphysema leads to poor gas exchange and contributes to the characteristic symptoms of dyspnea, hypoxemia, and hypercapnia in affected individuals. Therefore, the alveoli are directly associated with the pathophysiological processes of emphysema
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