The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Exudate

Pain

Hyperthermia

Hardening of the tissue

Answer and Explanation

The Correct Answer is C

A.   Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B.   Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C.   Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D.   Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

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Correct Answer is B

Explanation

A. Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B. Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C. Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D. Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.

A. A client who has swelling, tenderness, and purulent drainage around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

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The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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