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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Implement neutropenia isolation: Neutropenia isolation is not applicable for a client with C. diff infection. Neutropenia isolation is used for clients with low neutrophil counts to protect them from exposure to pathogens due to their compromised immune system.
B. Disinfect equipment with bleach solution: Clostridium difficile spores are resistant to many disinfectants, but they can be effectively killed by bleach solutions (sodium hypochlorite).
Disinfecting equipment with bleach solution helps prevent the spread of C. diff infection.
C. Monitor the client for manifestations of fluid overload: Manifestations of fluid overload, such as edema or shortness of breath, are not typically associated with C. diff infection. Monitoring for fluid overload is important in other clinical contexts, such as heart failure.
D. Use alcohol hand sanitizer following client care: Alcohol-based hand sanitizers are not effective against C. diff spores. Hand hygiene should be performed with soap and water, as alcohol-based sanitizers are not effective against C. diff spores.
Correct Answer is C
Explanation
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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